Victorian Inquest Dilemmas: the View, Bones, and Fires

[Dave O]

In 1883, there was a terrible fire at the Southall Lunatic Asylum, causing both loss of life and property:

The Times August 15 1883

FATAL FIRE AT A LUNATIC ASYLUM.
Early yesterday morning a fire was discovered at Southall-park, the mansion of which has for some time past been used as a private lunatic asylum. The building was erected by Sarah Jennings, Duchess of Marlborough, and was first inhabited by Sir W. Ellis, at one time medical superintendent of the county lunatic asylum at Hanwell. It subsequently came into the occupation of Dr. Stewart, who was succeeded by Dr. Boyd, formerly superintendent at the Marylebone Workhouse, and afterwards of the Bath and Somerset Asylum. He had occupied Southall-park about eight years, and received insane persons for private treatment, the average number of his patients being from 20 to 30. The fire was discovered by one of the female attendants shortly after 2 o’clock, and an alarm was at once given throughout the establishment; but owing to the hold which the flames had already obtained on the building, the greatest difficulty was experienced in rescuing the occupants, whose scrams aroused the inhabitants of the neighbouring village, many of whom were quickly in attendance, and rendered all the assistance they possible could. Foremost among these was Mr. James Abbott, son of the late editor and proprietor of the British Beekeepers’ Journal, who, by means of a ladder, entered a window on the first floor, and removed three female patients, whom he found crouching in a corner of the room. Other patients escaped in their night clothes, and were found clustered under the trees in the park, while one was found on the lawn in front of the building in an insensible condition. In the meantime messengers were dispatched to the neighbouring districts summoning the aid of the fire brigades, and within a quarter of an hour from the call, the Hanwell steamer, in charge of Captain Walker Abbott, arrived, but owing to the short supply of water, and its distance from the mansion, they were unable to get to work until the arrival of the Ealing Dean Manual, from which several lengths of hose were borrowed. Other brigades quickly followed, including the Ealing steamer, which, with borrowed hose, quickly got to work. It is remarkable, however, that, connected with an institution of this importance, there should have been so inadequate a supply of water, the nearest supply being from a shallow pond a quarter of a mile from the house. After the arrival of the brigades it was evident that nothing could be done but to save the outlying portions of the building, upon which the firemen directed their efforts, and continued to do so until they were assured that all attempts to save life were futile. Subsequent information proved that at least five bodies, including those of Dr. Boyd and one of his sons, were buried in the debris, and the efforts of the firemen and their numerous assistants were at once directed to the removal of the dangerous walls, prior to the commencement of the search for the missing bodies, which up to a late hour last night were not reached. The missing are:--Dr. Boyd, the proprietor of the asylum; Mr. W. Boyd, who was on a short visit home from Texas; Mrs. Cullimore, a patient; Captain Williams, a patient; and Elizabeth O’Lachlin, a cook. The injured are Elizabeth Howe housemaid, who sustained a serious cut on the head and concussion of the spine; Elizabeth Wilgros, kitchen maid, shock to the system from jumping out of a first-floor window; Mr. H. Boyd, nephew of Dr. Boyd, injury to the foot; and Miss Bronette Boyd, injury to the leg. Mr. Hutton, gardener, who sustained a broken arm, fractured ribs, and slight concussion of the brain, died a few hours afterwards. Drs. Alexander M’Donald, Burton, Willett, and Fenton were indefatigable in their attention to the injuried. Southall, a usually quiet country village, was in a state of great excitement in consequence of the fire; but, through the efforts of an ample contigent of police, under Superintendent Foinett, excellent order was maintained. Estimated damage £25,000. . .

[Dave O]

You'd think this would be a good reason for holding an inquest--you've got loss of life in a public institution, and an apparent need to review the response to the fire (the lack of water to put it out). Plus, relatives and the public seemed to have wanted answers. However, the relevant coroner, Dr. Thomas Bramah Diplock, refused to hold an inquiry:

Times August 21 1883
THE FIRE AT SOUTHALL.
Dr. Diplock, the Coroner for West Middlesex, does not consider that the few fragments of calcined human bones found among the burnt building materials at the scene of the recent fire at the Southall Lunatic Asylum are sufficient to justify him in holding an inquest upon them, a decision which was quite unanticipated in Southall and has created no little dissatisfaction among the residents, many of whose places of business are still partially closed with shutters as marks of respect to the deceased. It was the opinion of Dr. M’Donald, who for several days watched the excavation of the ruins in order to collect the remains of the victims, that the finding of the vertebrae was enough to warrant the opening of an inquiry into the circumstances attending the deaths of Dr. Boyd and the four other residents. Upon that assumption, Mr. Hancock, the parish officer of Southall, immediately communicated with Dr. Diplock, who after very careful consideration, declined to accede to the request, although interviewed likewise upon that subject by Mr. Kingston, the representative of the Misses Boyd, the late doctor’s daughters. In reply to Mr. Hancock, Dr. Diplock writes:--“I do not consider that inquests can be taken upon the bones of the persons found in the ashes of the house at Southall-park.” Under these circumstances, there is, much to the disappointment of the public, very little probability of any further inquiry being made into the dreadful calamity. The calcined bones of the deceased lie in one of the upper rooms of the infirmary of the ruined asylum, in the custody of Pearson, one of the members of the London Salvage Corps, who has the charge of the property rescued from the fire. During Sunday the scene of the conflagration was visited by a large number of people, who, however, were not permitted to enter the park, which was kept from intrusion by Mr. Callcott, several of the Earl of Jersey’s workpeople, and the police. The ruins of the mansion remain as they were left by the searchers at the close of the explorations on Saturday.

[Dave O]

Diplock looks like a cold-hearted bastard here. People have lost their lives. What was his problem? I think an explanation for his refusal may be found in the fifth edition of Jervis, written a few years later. The editor's commentary on holding inquests on skeletons:

So, if an inquisition be quashed, the body may, by order of the Court, upon motion be disinterred for the purpose of taking a second inquisition; but the Court will exercise a discretion in making or refusing the order, according to the circumstances of the case, and the length of time the body has been buried. So essential is the view to the validity of the inquisition, that if the body be not found, or have laid so long before the view, that no information can be obtained from the inspection of it, or if there be danger of infection by digging it up, the inquest ought not to be taken by the coroner, unless he have a special commission for that purpose; but as the proceeding before the coroner is one only of several, application should be made, in such cases to the magistrates, or justices authorized to inquire of felonies, &c., who, without viewing the body, may take the inquest by the testimony of witnesses. Indeed, it would seem that coroners may be amerced for taking up a body that has been buried so long, that, from its state of decomposition, no information can result from the view; and that, in such a case, the Court into which the inquisition is returned may, upon affidavit of the circumstances, refuse to receive and file it. (R E Melsheimer, The Coroners’ Act, 1887, With Forms and Precedents. Being the Fifth Edition of the Treatise by Sir J Jervis on the Office and Duties of Coroners. London: H Sweet & Sons, 1888, 27–8.)

What I take from the above is this: Don't hold an inquest on bones, because you've got to have the view, and in these cases, you can't tell much about identity and cause of death from a bunch of old bones. Diplock, I think, doubted that he could hold a proper inquest from vertebrae.

[Dave O]

A helpful illustration on the problem here is when a different coroner exercised a different discretion than Diplock did in 1883. In 1892, skeletons were unearthed in Spitalfields:

The Times, 10 October 1892:

Information was received on Friday by the police of the H division at Commercial-street station that a quantity of human bones, together with three skulls, had been found by workmen engaged on buildings in course of erection at Flower and Dean-street, Spitalfields. The facts were inquired into on Saturday, and it was found that two workmen at the buildings referred to were engaged in excavating for the foundations of a wall when they came upon some bones and a box containing two skeletons of adults. A third skull, that of a child, was also found. The wood of the box did not look like coffin wood of the ordinary kind, and in getting it out of the hole in which it was found it was broken to pieces. The bones, too, were scattered and mixed up with the excavated earth, and only a very small portion of the three skeletons could be handed over to the police and to the coroner’s officer. Mr Hewett Oliver, surgeon, of Kingsland, examined the bones on Saturday, and while agreeing that they were the remains of a child about eight years old and of two adults – a man of middle age and a woman about 70 – found that so much of the skeletons was absent that he could pronounce no further opinion. Plain clothes constables have been set to work to sift the earth excavated and to endeavour to discover any further portions of the remains or other matters likely to throw further light on the matter. Whether an inquest will be held will be for the coroner, Mr Macdonald, to decide after the medical examination is complete. It is the medical opinion that the bones have been interred for some 20 or 30 years.

Where Diplock hesitated, Dr. Roderick Macdonald proceeded:

The Times, 12 October 1892:
At the Town-hall, Shoreditch, yesterday, Dr R Macdonald, coroner for North-East London, held an inquiry with reference to the discovery of human remains on the site of a common lodging-house at Flower and Dean-street, Spitalfields. The evidence showed that some workmen in the employ of Messrs. Pete Brothers are engaged at the present time digging a trench for a concrete wall on the site of what was formerly 6, Flower and Dean-street. On Thursday last a skull was found, and on Friday morning two skeletons in a box, or coffin, were discovered. Subsequently the police made a very careful search of the ground, and brought to light a great number of other bones. The lodging-house, which consisted of three houses thrown into one, had been in the occupation of the same tenant for 40 years. The leaseholder was a Mr Ritchie, of Well-street, Hackney, now 83 years of age; he took over the premises in 1851, when they were inhabited by persons of the lowest class. Inspector Seabright, H. Division, deposed that he had made inquiries of various people. One old lady said that she could remember the houses 80 years ago. At that time they were occupied by Spitalfields weavers. Witness had also learnt from old records that in 1765 a riot took place in Spitalfields, and following this an attack was made upon some of the weavers who were using improved looms. Various outrages followed, and a number of lives were lost. Dr Franklin Hewitt Oliver, of Kingsland-road, deposed that he had carefully examined the bones. There were in all 150 bones and 18 fragments of bones, not including three fairly-complete skulls, one skull in 11 fragments, and a bone each of three other skulls. He had pieced them together, and formed the opinion that they were the remains of seven persons – four adults and three children. There was nothing about any bone indicating disease, injury, or violence before death, or giving any suggestion as to the cause of death. Among the articles he examined were the jaw bones of sheep, the tooth of some animal. He was [of] opinion that the bones had been in the ground from 75 to 100 years. The coroner remarked that when discoveries of this kind were made it was only right and proper that a public inquiry should be held, so that the matter, if possible, might be cleared up. The jury thanked Dr Oliver for his evidence, and returned verdicts to the effect that the bones were found buried, but that the evidence failed to show who the deceased persons were or how they died.

I think this is a failed inquest--the bones couldn't be identified, the cause of death couldn't be determined. They may as well have not had this inquest, despite Macdonald's justification. Because of the view, inquest was not a good vehicle for investigating this case.

The view, necessary for all inquests then, could seriously inhibit investigations.

[Dave O]

What I think was needed to investigate fires and skeletons properly is to allow coroners to dispense with the view. However, it was reenacted in the Coroner's Act 1887. It's true that the High Court received a power to dispense with them when they quashed inquests and ordered new ones (in 1876, the Justices had tried to get around exhuming Charles Bravo when they quashed the first inquest into his death), but for all primary inquests, the coroner and jury still had to view the body.

But earlier in the 19th century, coroners had been holding inquests for fires where no one had died at all. In these inquests, the view had been entirely dispensed with because there were no deaths, no bodies. These inquests were controversial, and while their value was recognized, their legality was questioned: if the view was a legal necessity for an inquest to be held, then how could a coroner investigate a fire that had killed no one?

[Dave O]

The medieval coroner investigated everything in the interests of the Crown. It is thought that he also investigated arson. I haven't studied the ancient version of the office, but this is the justification that's discussed mid-19th century:

Go to the places where any be slain, or suddenly dead, or wounded, or where houses are broken...(4 Edward 1, "De Officio Coronatoris" [The Office of Coroner]

This is the basis that coroners working in the first half of the 19th century used to investigate arson with no associated death, reviving an ancient practice out of obscurity. They were doing so all across England, but I think the most notable of them was City of London coroner William Payne in the 1840s. And arson inquests were popular--I don't think many doubted the value of investigating fires that destroyed property and cost people a lot of money. But what the Victorians wondered was this: does the ancient statute mean that the medieval coroner went to the scenes of disasters to investigate sudden death, or did he investigate "broken houses" themselves? The practice was so old, nobody really knew. And local government, which funded inquests, was unsure whether these inquests were legal (because there was no view), and so began to refuse expenses associated with them. In the City of London, this practice seems to have dissuaded Payne from holding them, although successive City coroners continued to advocate the need for them.

And elsewhere in the country, coroners continued to hold them, though their legality was questioned. Finally in 1860, the High Court heard the case "Queen v Hereford"--Thomas Hereford was coroner for Manchester, and he'd been investigating arson with no deaths. And what the High Court decided was that, if the medieval coroner had ever investigated arson, the practice had been in disuse for so long, that Victorian coroners had lost the power. Coroners should confine themselves to sudden deaths, murder and manslaughter. Hereford was prohibited from holding any more fire inquests. The same I think would have been true for all coroners from 1860 on.

Yet, they continued to have fires, of course. Very notably in the City, which saw some significant losses of uninsured property, and finally saw that inquest might be a good way to investigate them. Inquests cost very little--even with the coroner's salary added in, I don't think they could have added up to much more than a few pounds each. And so, although the City's Common Council had questioned their legality forty years earlier, in 1888 fire inquests must have seemed very attractive because they were a cheap way to do it.

The problem they now faced was that per the Coroner's Act 1887, the only felonies that coroners could investigate were murder and manslaughter. Arsons were out. So the City got a private bill passed very quickly, The City of London Fire Inquest Act 1888: this enabled the City Coroner, and only the City coroner, to investigate fires without an associated death, and no view. Though like inquests for sudden deaths returned few accusations of murder, fire inquests returned few accusations of arson--but the publicity surrounding them was thought to be a preventative. Successive coroners in the City had this power until 1977.

They never spread to the rest of England, however--not that I know of, anyway. It's interesting to think that if other coroners had a similar power to dispense with the view, that Thomas Diplock might have been better enabled to investigate that asylum fire in 1883, which I think was badly needed and wanted--could he not have then dispensed with the deaths and vertebrae and probed the fire itself, it's cause and the response to it? With nothing like the City's fire inquest act of 1888, Queen v Hereford would have stopped a coroner's arson investigation cold.

Cheers,
Dave

[John Savage]

Hi Dave,

I think that one thing which could have influenced Dr. Diplock in his decision not to hold an inquest would be the matter of costs. As we know, the coroner had to have his costs re imbursed by the local magistrates, who were often concerned with keeping costs down and had the power to refuse to re imburse costs if they thought that an inquest was not nesessary. We also know from our past research that Diplock took a deep interest in money, his own in particular.

MacDonald was a weathier man than Diplock and was also an MP, with whom I guess the magistrates may have been less inclined to argue. He also would perhaps have found it easier to bear the cost.

Rgds
John

[Dave O]

Howdy John

Yes indeed--if he'd held that case, might his expenses have been disallowed, in which case he'd have been stuck with them (having paid for them out of pocket), or might he have even been punished for holding it? I don't know what the penalty would have been (perhaps the "amercement" might have been the disallowance of his expenses, there's probably a citation in Jervis that will explain it). And though I think Diplock was wealthy himself (by virtue of his Bramah relatives), we know he had his financial battles over expenses with the magistrates in the 1860s and 1870s.

Diplock was said to have been "parsimonious" with expenses in order to hold costs down.

As far as I know, Macdonald was all right in holding his inquest in 1892 (though I wonder if he got his expenses back).

Cheers,
Dave

[Dave O]

One thing I wanted to point out in this thread, but forgot to mention, is that although a coroner might be perceived as uncaring in a press account, he might actually have had some sound reasons for his actions, which newspapers may not have addressed, or he may not have gone into. Very frequently, for these sorts of reasons, I have found coroners to have been terribly misunderstood by their contemporaries.

[silverstealth]

Illustrated Police News, August 25, 1883

[Phil Carter]

Hello Dave, Mark, John,

Dave,
This is fascinating. I am getting a far better understanding of the Coroner's role after reading about this. Thank you, great posting!

Mark,
Superb! Ditto the above re asylums. One thing that strikes me is the graphic "licence" allowed for descriptive purposes in these drawings/engravings. Rather like the one of Bond and his unfortunate demise. It seems that in the absence of the camera, newspapers and the like were allowed to "set the scene" with as much reality as possible.

John,
Indeed. The question of expenses seems to have been a little sub-theme at the time.

best wishes

Phil

[Dave O]

Money

Thanks for that sketch, Mark.

Hi Phil,

Once inquests became funded from the county rates, there was a constant battle over money between county coroners and county magistrates (who oversaw finances). When coroners paid for inquests out of pocket, and then later paid a fee per inquest plus reimbursed expenses at the quarter sessions, this system gave the magistrates an unintended power of directing coroners on which cases they should investigate. If the magistrates thought an inquest unnecessary, they could disallow payment for that case, which could inhibit the coroner's future conduct. The fear was that homicides that weren't readily apparent, like poisonings, might remain undetected.

That was partially remedied in 1860, when coroners began receiving annual salaraies based on populaton, mileage, and number of inquests held. The salaries were held in place for five years, allowing the coroner to function without interference. At the end of five years, the magistrates had an opportunity to review the salary, and the coroner had an appeal through the Home Secretary and the Privy Council. Expenses however, were still awarded on a quarterly basis, and at the end of five years, magistrates did not always seize the opportunity to revise salaries, although population and the number of inquests had risen.

[Dave O]

Dr. Diplock took his case to the press.

The Times, 21 July 1879:

[On] the 8th of May, 1876, I attended by invitation a meeting of a committee of the Middlesex magistrates ‘to confer on the salaries,’ when my return of inquests and of miles travelled was accepted and my salary for the ensuing five years assessed at £961 18s 10d.

On the 2nd of June, 1876, I received a letter from the Clerk of the Peace informing me that a resolution had been passed at Quarter Sessions ‘that no alterations be made in the salaries of the several coroners.’ I consequently, in accordance with the Act 23 and 24 Vic, cap 116, appealed to the Home Secretary ‘to fix and determine the amount of such salary.
On the 24th of August 1876, at the Quarter Sessions, a letter was read from the Right Hon R A Cross [the Home Secretary] in which occur the following sentences:

["]The report admits considerable increase of inquests and mileage in both Mr Payne’s and Dr Diplock’s districts. Nowhere is it stated that the magistrates were dissatisfied with the figures returned, – that either unnecessary inquests had been held or unfair mileage charged... Mr Cross considers that if an increased number of inquests have been fairly held and an increased expense for mileage incurred, such elements should not be entirely left out of the calculation in arriving at the basis of what is a fair salary to be paid to those coroners for the ensuing five years.["]

The magistrates then passed a resolution that: The justices have now no means of discovering in what cases inquests have been fairly held, but have still every reason to believe that the larger number are unnecessary and improper.

On 1 September 1876, a letter was sent from the Home Office informing me that Mr Secretary Cross had fixed my salary at £650 per annum. This was without allowing me to disprove the scandalous allegation, and though to him and then to the chairman of the magistrates asking for investigation to prove or disprove the charge, the only redress I received – if redress it can be called – was a letter from the Clerk of the Peace, dated December 5, 1876, in which is this sentence: “I am also to call your attention to the fact that you were not individually mentioned in the resolution referred to in your letter.”

The Coroners Bill to be considered on Monday leaves it to the local authority to fix the salary. My salary has thus been fixed at £650 a year, out of which I have to pay all my office expenses and travelling, also for assistance from the deputy-coroner: also I have to advance money to pay the disbursements of the inquests, amounting at times to more than £300 out of pocket at once.

Last year I held 685 inquests, paid £1,316 19s 6d. in fees and disbursements, and travelled at my own charges about 3,500 miles, at my salary of £650, besides having made careful inquiries as to other 239 reported cases in which I did not consider inquests necessary.

I think these are facts that should be publicly known when it is proposed to place the determining of the amount of coroners’ salaries in the hands of the local authority, and as the Coroners Bill is about to be considered by the House of Commons, it appears to me that this is the fittest time to lay them before the public.

Apologizing for the length of this communication, I will only add that the salary of this division of the county has been increased only £50 a year in 14 years, whereas the population has risen in that period from 285,000 to about 600,000.

[Dave O]

The following year, this criticism appeared in the press.

The Times, 19 November 1880

Sir,

Will you allow me to give a simple statement of what has just occurred in this parish, in order to show the grievous wrong inflicted on the poor by the present working of the law of inquest? The law says: ‘The coroner has no authority to take an inquisition of death, except upon view of the body by himself and the jury; and if he does so, the inquisition is wholly void.’

My tale is this: On Monday week a young wife died, after being confined with a dead child. The funeral was to have been held last Sunday, which seemed hardly soon enough, but there was a common difficulty about bearers at work and friends from a distance. On Sunday morning we were told the funeral must be put off that an inquest might be held to inquire into the conduct of the midwife for not having sent for a doctor when dangerous symptoms set in. The inquest was not held until this morning, and the funeral is only just over – that is to say, the dead bodies have been left from Monday in one week to Wednesday in another. The relations have behaved extremely well in the circumstances, but their trouble has been much aggravated by the fact that the poor girl’s mother, daily expecting her own confinement, is under the same roof in the next cottage.

Now, bad as this case is, and far worse as it might have been in hot weather, perhaps no one is much to blame except the law that coroner and jury must see the dead. The Registrar lays a hesitating certificate from the doctor before the Board of Guardians, who forward it to the coroner, who comes when other engagements permit. And yet what has happened ought not to be possible. We endeavour to set the poor free from that loving superstition which holds fast their dead until corruption has done much of its work; we speak of typhus and other probable harm to the living, and then the law comes to sanction horrors which even they protest against vehemently. And all this for what cause? That unwilling and shrinking jurymen may be compelled to the ghastly sight of bodies dead ten days, when their verdict could not possibly be affected by it. If any one has been killed by a gunshot, it may be necessary to inspect the wound, but why bring them before the dead in a case like this, when all but professional opinion is worthless? A doctor was present at the birth of the child; his opinion, not that of the jury, is required. Surely this law requires alteration.

[Dave O]

Diplock's reply, which appeared the next day:

The Times, 20 November 1880

Ostensibly written to deprecate the necessity of a coroner’s jury having to view the body on which an inquest is held, the letter is made a means of insinuations, of latent causticity, bearing on the reasons why the inquest was held, and the cause of delay in taking it is attributed to the coroner’s having ‘other engagements,’ – the delay being stated as of ‘ten days’ extent.

The inquest was taken to ascertain and take evidence whether the midwife had contributed by rash or violent means to the woman’s death, and cases have occurred of such nature as to necessitate a charge of manslaughter against midwives. Therefore, it is not justifiable to say that it was held ‘to inquire into the conduct of the midwife for not having sent for a doctor when dangerous symptoms set in.’ As to the delay ‘from Monday in one week to Wednesday in another,’ I can only say that the information of the case first came to me on Monday, and I held the inquest on Wednesday – that is to say, two days after I received the information. The danger to neighbours and residents would be best obviated by the erection of mortuaries in similar cases, but in this instance the disanguined condition of the body should have prevented any supposition of danger of exhalations.

Such critical letters are of service when strictly correct, and I am well aware that changes must be made in the office and duties of coroners before many years are over, but such change should be radical, and not tentative, as in the Bill printed by the late Government; and I cannot but think much light might be thrown on this subject if the Home Secretary would address a circular to the coroners asking for suggestions (as he has done to the various Quarter Sessions in reference to the punishment of juvenile offenders), and allowing their suggestions due consideration.

The population of my division of the county has doubled in the last ten years, and the number of inquests consequently increased, whereas my salary of £650 (out of which all expenses have to be paid) remains the same as it was ten years ago, so that it is probable delays in holding inquests will occur simply from my inability to provide necessary assistance. Primarily, then, any such cases must be assigned to the ruling motive at the Quarter Sessions – that it is a first duty to save the rates, and this sanctioned by the decision of the late Home Secretary on my appeal to him nearly five years ago.