A Stream of Lives

Historical biographies

Tag: coroner

Hats in the canal – a miscarriage of justice?

11 February 2026 / / 0 Comments

On the afternoon of Thursday 7th May 1840, two boatmen were walking along the towpath of the Birmingham and Fazeley canal when they came across a man’s hat, dry and undamaged, sitting on its crown under a bridge. Surprised by this unexpected find, they glanced around and spotted a woman’s bonnet floating in the water a few feet away. The bonnet was soaked and badly crushed.

Alarmed about the fate of the hats’ owners, the men grabbed a boat hook and dipped it in the water. After swishing around for a few minutes, the hook caught on a woman’s dress. To their horror, the men realised they had found the corpse of a drowned woman. The boatmen hauled the body out of the water and called the police. The policeman who responded recognised the hats as those belonging to Harriet Wright, aged 19, and her lover, a 17-year-old apprentice named Josiah Lilly.

Boat on a canal
A Birmingham canal [Birmingham Museums Trust]

The inquest

Harriet’s inquest took place the following day, presided over by Birmingham Coroner John Birt Davies. Numerous witnesses were called and a large audience piled into the temporary courtroom in the Turk’s Head pub. A tragic story emerged of a young woman caught between her love for a mercurial young man and her father’s strong objections to their union. Harriet and Josiah’s relationship had been turbulent, alternating between periods when they cohabited in apparent harmony, and times when she left him to return to her father’s house.  

Lilly was known to the police, who had recorded a list of previous warnings for bad behaviour. A few days before, he had been taken into custody accused by Harriet’s father of stealing her hat and shawl. A policeman noted that Lilly responded aggressively when Harriet asked him to return her clothing, but she declined to press charges, so he was released. On being picked up again following her drowning, Lilly seemed an obvious suspect and was taken into custody.

Josiah Lilly was brought into the inquest looking noticeably young, but self-possessed. The inquest jury had to decide whether Harriet had taken her own life by jumping in the canal, or whether she had been pushed, in which case Lilly could be held guilty of murder. After questioning witnesses for the entire day and listening to the coroner sum up the evidence, the jury retired to a private room to consider their verdict.

The verdict

It was getting on for midnight when they returned to announce their verdict, watched by the large crowd of onlookers gripped by the dramatic accounts. The foreman stood up: ‘We are agreed that the deceased came by her death by drowning and record a verdict of wilful murder against the prisoner.’

The assize court

This conclusion required Lilly to be referred on to the assize court to be formally tried in front of a judge, lawyers for the prosecution and defence, and a jury. The case came before Worcester assize court fourteen weeks later. The same witnesses appeared and were taken over the same ground as in the inquest, but this time Lilly was defended by a very able lawyer.

Claiming Harriet was ‘a person of hasty temper’, Lilly’s defence lawyer argued that he had no motive for killing her. ‘Had the jury never heard of women destroying themselves for love?’   Much of his case rested on the hat and bonnet. Lilly had taken Harriet’s bonnet to persuade her to return to him, but her father had taken advantage of this to accuse him of theft. The fact that Lilly’s hat had been found in the only dry place under the bridge, he suggested, was an indication that Harriet had placed it there to implicate him.

The astonishing imputation that she had taken her own life and, in the process of doing so, had the foresight to implicate Lilly in this way seems incredibly far-fetched. But it served to plant doubt in the minds of the jury, who returned a verdict of not guilty, and the prisoner was duly released.

For more information on this and other coroner’s tales, see Probing Deaths, Saving Lives.

The Coroner’s Roll

20 March 2025 / / 0 Comments

Recently I was delighted to receive an invitation to give a talk at Birmingham’s Central Library about the city’s first coroner, Dr John Birt Davies, the subject of my recent biography. As an extra inducement the organisers had arranged to bring his Coroner’s Roll out of storage. Usually locked away in the archives, the historic document was laid on a table, allowing all of us there to pore over it.

Photo of a coroner's roll
John Birt Davies’s coroner’s roll [Birmingham Library Archives]

Measuring 100 yards in total, the roll details every one of the 30,000 inquests he presided over in his thirty-six-year tenure as Birmingham’s borough coroner from 1839 to 1875. It lists the names, ages and addresses of the deceased, their occupations, the place of death, location of the inquest (usually a pub in the same district where the person died), the cause of death, the verdict of the inquest jury, any fines levied on those held responsible, and the costs incurred (room hire, jurors’ fees, fees for the coroner’s clerk, etc).

Many of the records hint at tragic circumstances. For example, the list of inquests carried out in 1839 records the death of four-year-old Sarah McNalla, daughter of a labourer, who died in the workhouse from ‘starvation and the inclement mercy of the weather’. And John Britshott, a pocket-book manufacturer from Foredraught Street, was found to have hung himself while in a state of temporary insanity. And then there’s William Kite of Yardley, a labourer, whose death from ‘effusion of blood in the head’ was apparently the result of wilful murder by ‘some person or persons unknown’.

The office of coroner has a long history in England, dating back to the 12th century. Appointed by the crown, they were originally royal tax collectors who gathered death duties, but by the Victorian period the role had evolved into a judicial officer responsible for investigating sudden and unexplained deaths.

Coroners worked hard to ensure that sudden deaths were investigated thoroughly. The first task was to recruit a jury of at least twelve local men – women could be witnesses but not jurors. The jury’s first task was to examine the body in the presence of the coroner, enabling the death to be certified prior to burial. This had to be organised very speedily – there were no morgues or refrigerators in those days.   

The most diligent coroners made sure the relevant authorities were alerted to means of preventing future deaths. Birt Davies was particularly concerned about the high rate of child deaths in Birmingham, many of which were caused by severe burns. He noticed that girls were more likely to die from this cause than boys, and he put this down to their aprons or loose pinafores that could easily be ignited by sparks from the family’s fire. He was disappointed when his proposed solution – subsidising the cost of less flammable materials – was not immediately adopted by the borough council.

For more information on this and other coroner’s tales, see Probing Deaths, Saving Lives

Birmingham heritage

11 February 2022 / / 0 Comments

Just back from a trip to Birmingham to do more research for my forthcoming biography of John Birt Davies, Birmingham’s first coroner. The Wolfson Centre archives at Birmingham Central Library yielded some fascinating material, including microfilms of the register kept by Davies of the 30,000 inquests he presided over from 1839-1875.

I hadn’t been to the new library before. It’s extraordinary on the outside with its grey and gold layers covered in metal filigree rings – not my taste I have to say – but inside it’s stunning, with a circular design spanning ten levels. And almost every study space in the huge library was occupied, mainly by students, so it’s obviously providing a really useful service for young Brummies.

Tracing the coroner’s footsteps was more difficult. He arrived in Birmingham in 1822 after completing his medical training at Edinburgh University. He set up his first medical practice at 19 New Street, but no trace of the original building remains in this central shopping street. After his marriage to Sarah Redfern, the family home and medical practice moved to 25 Newhall Street where they lived until his retirement. Disappointingly few buildings from that era remain. Their last home was at 280 Hagley Road, Edgbaston, but that building has gone too.

Birmingham suffered greatly from bombing during WW2, but much of the destruction has happened since the 1960s. Those responsible for the mid-twentieth century developments favoured motor cars over pedestrians, but there’s been a change of heart since. Redevelopments at New Street Station and the Bullring are more successful, and the pedestrianisation of Centenary Square will be a triumph if it’s ever finished.

Most museums and galleries were shut at the time of our visit (Feb 2022), including the main museum in Chamberlain Square that I had very much wanted to see. It was undergoing renovation and there were signs of frantic activity to get everything ready in time for the 2022 Commonwealth Games, due to open in Birmingham on July 28th.

In Victorian times coroner’s inquests were held in pubs, often with the dead body present. I had hoped to find some of the old pubs still standing, particularly the Grand Turk in Ludgate Hill where many inquests took place, but sadly most have disappeared. I found just one where Davies had presided – the George and Dragon on the corner of Albion Street and Carver Street, now lovingly restored and renamed the Pig and Tail.

Old George and Dragon, now Pig and Tail
Pub where inquests used to be held

Despite the wanton destruction of Birmingham’s heritage, I did make a few more exciting finds. The Davies family tomb in Edgbaston Old Church, with memorials to my great great grandfather, great grandfather and father is still there, as is the tomb of Clement and Ann Cotterill, my fourth great grandparents, in the graveyard of St Philip’s Cathedral.

And it was great to see once again the clocktower erected in honour of John Birt Davies still standing by the Five Ways roundabout. The clock had stopped, though, and it was in desperate need of a new coat of paint. Birmingham City Council – please wake up!

Victorian clock
Memorial to John Birt Davies at Five Ways, Birmingham

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