The Coroner’s Roll

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.

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 12^th 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.