Defending the Open and Public Nature of the Coronial Inquest
Late in October 1829, The Australian’s reporter ‘HT’ was both deeply displeased, and also rather disconcerted. He had heard of a sudden death at the Female Factory, but he had not been permitted to observe the subsequent coronial inquest. The woman had reportedly been in good health during the daytime on Sunday 25 October, but she had unexpectedly expired sometime during the night. Now the ‘shocking sight’ of her body was laid out supposedly ‘black as ink.’ Yet the reporter, as an impartial observer, was denied access to the proceedings. The gatekeeper resolutely refused him entry. Then the matron, Ann Gordon, came out and also shooed him away. No person was to be permitted entry and the factory gates were ordered to be kept firmly shut. This was most irregular indeed. Because not only was it ‘HT’s’ job to report on such affairs, open access to the coronial inquest was also a long-held civic liberty dear to the hearts of every Englishman.
The Coroner and his Jury
The office of the coroner had originally been created in the twelfth century to serve as a revenue collector for the King. Fines and death duties were kept and recorded by him. The coroner was also responsible for the recovery of treasure troves and booty from shipwrecks and smugglers. And the coronial inquest into violent, sudden, or unexplained deaths was also part of his responsibilities. The death inquest was always a very public affair. With a popularly elected coroner and a jury of twelve local laymen, the inquest served as a traditional check on authority by an active and watchful citizenry. The jury had the power to question witnesses, return verdicts and recommend that a person be committed to take their criminal trial for murder or manslaughter. They also had the power to issue riders which sometimes praised, but more often than not, sternly admonished someone or something that had been involved in the sudden death. Riders also often made recommendations and suggestions. If the inquest was held into a tragic accidental death of a young child, they might strongly exhort parents to take more care and watch over their toddlers and bairns near to deep dangerous wells or open kitchen fires. On occasion, riders made recommendations to reward a person who had heroically tried, but sadly failed, to save the deceased from a watery grave or a burning building.
In June 1829, Thomas Foreman Esq was appointed by Governor Ralph Darling to serve as the coroner for the Parramatta district. There was also a coroner in Sydney and others out at Richmond, Windsor, Penrith and Bathurst. Like most nineteenth-century coroners, Thomas Foreman was a gentleman and a lawyer. In England, coroners were popularly elected by householders for life. However, in colonial New South Wales, they were appointed by the Governor. In the social-climbing milieu of the convict colony, many coroners resigned when a more lucrative, elite government position became available. Foreman’s predecessor John Delhunty Esq only retained the position of Parramatta coroner for a few short months before he tended his resignation. However, some had long and successful careers and died whilst still in office. Thomas Foreman himself resigned after certain scandalous allegations of unprofessional conduct were made regarding his coronial career. Rather tragically, he himself died at the Liverpool Lunatic Asylum on Monday 31 October 1831.
A coronial inquest was always convened when a sudden, strange or suspicious death occurred. With a hastily convened jury of twelve local respectable ‘true and good’ men, the coroner would guide the proceedings and hear from witnesses about the circumstances leading up to the death. Importantly, all such deaths in government institutions—the gaols, lock ups, factories and lunatic asylums—were also investigated by the coroner. Such inquests would hear evidence and statements from both the staff and fellow inmates. Institutional inquests sought to serve as a check upon any possible hidden-behind-walls abuses such as insufficient or inedible food, wilful neglect or undue violence. They served as an important bulwark against institutional abuse, corruption, and possibly even wilful cover-ups of unlawful deaths in custody.
The jury’s role was to decide on the cause of death. Had it simply been a natural death? If so, the jury would return the religiously inclined yet medically imprecise verdict of ‘died from the visitation of God’. Or had there in fact been someone at fault, or something else more nefarious behind the death? Violence or foul play perhaps? If such a verdict was returned, a suspect might be handed over to the custody of the police and committed to take their trial at the next sittings of the criminal court. Or, if the accused was in fact at large, a bounty would be placed upon their capture. The inquest, then, was a civic duty and also an important restraint on both institutional mistreatment and potential crime. And so, on this occasion, The Australian’s reporter ‘HT’ was right to feel aggrieved. Because, by its very nature and throughout its long history, the ‘crowners quest’ had also always been a thoroughly open and public affair.
A Very Public Affair
Inquests were always held in public places. Long before dedicated coronial courts were built, the tavern, the hotel or the local courthouse were spaces where inquests would gather. The courthouse at Parramatta was regularly used by the district coroner during the 1820s. Quite simply the proceedings required a building with sufficient room to accommodate the gathering of the coroner, his twelve jurymen, the deceased’s family and friends, and witnesses willing to swear testimony. A doctor would always be present and usually a local watchman or constable too. Remarkably, inquests in country areas of New South Wales would continue to be held in public houses well into the Depression years of the 1930s. The dead body would also be present at the inquest, laid out for inspection. Indeed, an inquest was not a valid legal proceeding until the body had been identified by someone who had known the deceased in life. The body also had to have been inspected by the gentlemen of the jury. If the deceased had come to a violent, gruesome end and the body still lay where it had been slain, the jury might visit the scene of the dreadful crime to make their inspection. In the days before refrigeration and in the heat of the Sydney summer, the dead would begin to decompose rather rapidly. The requirement that the body had to be physically inspected by the jury helps us to understand why inquests were very often hastily convened affairs, often within a few short hours following a sudden death.
The inspection of the body even applied to those inquests which were held on exhumed bodies. Exhumation was not common but, when suspicions were raised that the deceased had perhaps died in dubious or questionable circumstances and had already been buried, the coroner might order the body to be disinterred. This, naturally, would have made for a rather frightful visual and olfactory experience indeed.
On occasion, the coroner would order a post-mortem examination to be carried out. And a professional medical opinion into the cause of death was always offered by a doctor. Whilst this took the proceedings into the elite sphere of the medical expert, the inquest remained a deeply democratic and participatory affair. The doctor’s opinion was not in fact always heeded. Moreover, anyone who knew the deceased—family, neighbours, friends or fellow work chums—might give an opinion to the coroner’s inquest. The nearest and dearest proffered insights into the habits and the ways that the deceased had lived. They thereby also tendered clues into the possible cause of death. How a person had lived often spoke volumes about their death. Their death, in turn, sometimes a telling story into how a life had been lived. And every possible kind of death might be so discussed in the public space of the tavern room or the hotel bar.
The inquest was investigative rather than inquisitorial. In cases of self-murder, witnesses might be asked about the mental state of the deceased. Had they been worried or distracted before they put an end to their existence? Maybe ‘pecuniary embarrassments’ or ‘affairs of the heart’ had led them to commit their rash act? Inquests into seemingly accidental deaths were often conducted to ascertain if it had in fact been an accident and that there had been no wilful or negligent behaviour on the part of another that might have contributed to the untimely death. Had the buggy driver been driving his horse furiously or at a gentle pace before the accident fatally knocked down the young lad? Was the hired boatman drunk whilst rowing his now drowned lady passenger across the harbour? And had the quack chemist wilfully or accidentally poisoned his patient with a fatal overdose of arsenic?
Deaths by violence in colonial New South Wales were common. Yet deciding if it had been accidental or intended was often tricky to decide. At some inquests, a whole cacophony of conflicting witness testimonials with accusations and allegations were heard to confuse the jurymen. In cases of fisticuffs or tavern brawls which ended in death, the evidence was often conflicting quite simply because such fights often happened after dark and after all concerned had been drinking strong grog. Memories might be hazy. Had a fist struck a fatal blow? And if so, whose fist? Or perhaps the deceased had fallen heavily whilst inebriated and struck their head on the road or against a brick wall?
Perhaps not surprisingly, the temperance or otherwise of the deceased was always enquired into. And a temperate, sober life might in fact lead to a much more ‘respectable’ verdict of cause of death, because juries could be greatly swayed by the knowledge that a person had led a sober life rather than a dissipated one. The verdict of death by ‘natural causes’ or died from the ‘visitation of God’ were far kinder and less judgemental than the disreputable and disgraceful one of having lived life as an intemperate rotten drunk. Such lives, marred by the excessive and improper use of ardent spirits, were recorded in death as having been sacrificed on the altar of intemperance. The demon drink and its role in the life and death of a person would continue to be a central feature of coronial inquests well into the twentieth century.
Women played an important role in coronial inquests. They were the traditional nurses, natural midwives and carers of the sick and the dying. And it was women who had often been the last to attend to the deceased. In cases of infanticide, it was local women who would be asked to confirm or refute allegations that a woman had recently been ‘with child’. A quick examination of the mother would soon put such rumours to bed. Or perhaps confirm them. Death was news and occupied conversations between neighbours. As did local gossip and rumour over back yard fences, amidst the bustle of the market places, on the wharves and in the local taverns and inns. And even this, seemingly idle chatter, might shed light upon an unexpected or suspicious death. In colonial Sydney, people knew one another’s business. And sudden deaths in the local community that were particularly ‘women’s business,’ perhaps a death in childbirth or one at the hands of a notorious brute of a husband, would also see local women regularly participate in the subsequent coronial inquest.
Democratic and free, the public had the right to attend and participate in an inquest. Everyone — men, women, and often children too. It was a people’s court deeply embedded in a long tradition of open watchfulness. Some went along simply to be nosy. Others to be shocked, informed, perhaps even ghoulishly entertained. And the newspaper press also had the right to report on the proceedings and comment, editorialise, pass judgement and, on occasion, roundly condemn or criticise a particular coroner, or a jury’s verdict. But they rarely questioned the sacred and long-held tradition of the inquest itself. Because it was an important bulwark against the corruption and the abuse of the privileged, the powerful, and all those who held a position of authority. And it had been for a very long time.
‘This Most Recluse and Sanctified Asylum’
So ‘HT’ was both perplexed and affronted in October and November 1829. As he himself wrote, ‘inquests of that nature ought to be conducted in public and not with closed doors.’ It later transpired that Coroner Foreman and his jurymen would have been perfectly happy for the hapless reporter to have been present and taken notes of the proceedings so that they might be ‘rendered public’. So what were the powers that be at the Female Factory trying to conceal? Had the death of the woman been a nefarious one? And if it had not been, why had ‘HT’ not been permitted into the inquest? Or was Matron Gordon trying to cover something else up?
Exposure and transparency had been part of the coroner’s inquest for centuries. They were also principles central and dear to the writings of the English philosopher Jeremy Bentham. The enlightened pioneer of the open, watchful, panopticon system of penal surveillance and discipline believed that ‘mystery was a fertile ground for calumny’ and ‘suspicion always attaches to mystery.’ Certainly, the refusal to permit ‘HT’ into the inquest at the Female Factory had immediately raised his suspicions that corruption, collusion or even cover-up were involved in the death of this particular unidentified inmate. As The Australian later remarked, with a rather thinly veiled nod to Benthamite distrust,
‘If there was nothing to conceal, nothing to apprehend, surely there could be no need of privacy. Mystery always begets suspicion…’
Take away the mystery, then, and such suspicions would simply abate.
The coronial inquest was not so much designed to reveal abuse. To be sure, on occasion, it certainly did just that. But rather, it sought to confirm its very absence. And this could only be done with a crystal-clear transparency and public openness — not hidden surreptitiously behind the solemn gloomy walls and the high gates of the Female Factory. As long as the barricades were up, the whiff of something sinister, perhaps a hint of scandal, would linger faintly, hovering in the dim shadows of the factory’s already rather dubious reputation. For so long as there were secret inquisitions here and, indeed, elsewhere in the convict colony’s barracks, factories, gaols and asylums, whispers and suspicions of neglect, abuse, mismanagement, cruelty and even wilful death itself, would continue to swirl and dance in the lusty colonial breeze.
Catie Gilchrist, “Mystery Always Begets Suspicion”: Defending the Open and Public Nature of the Coronial Inquest,” Female Factory Online, (2018), https://femalefactoryonline.org/essays/mystery-always-begets-suspicion/, accessed [insert current date]
Jeremy Bentham, “An Essay on Political Tactics: Chapter II: Of Publicity,” in John Bowring (ed.), The Works of Jeremy Bentham, Vol. II, (Edinburgh: William Tait, 1838–1843).
Ian Burney, Bodies of Evidence: Medicine and the Politics of the English Inquest, 1830–1926, (Baltimore and London: John Hopkins University Press, 2000).
“CORONER’S INQUEST KEPT PRIVATE. To the Editor of The Australian, Parramatta, Nov. 17,1829,” The Australian (Sydney, NSW: 1824 – 1848), Friday 20 November 1829, p.3.
“FASHION OF CONDUCTING INQUESTS AT THE PARRAMATTA FEMALE FACTORY,” The Australian (Sydney, NSW: 1824 – 1848), Friday 27 November 1829, p. 2.
 “Coroner’s Inquest Kept Private. To the Editor of The Australian, Parramatta, November 17, 1829,” The Australian (Sydney, NSW: 1824 – 1848), Friday 20 November 1829, p. 3. Ann Gordon became matron of the Female Factory in October 1827. Her annual salary was one hundred and fifty pounds. See Annette Salt, These Outcast Women: The Parramatta Female Factory, 1821-1848, (Sydney, Hale & Iremonger, 1984), pp. 58–9.
 Riders were not legally binding however a rider was a definitive and further unanimous expression of the jury’s democratic opinion. Some were acted upon, others were simply ignored.
 “Government Notice, Colonial Secretary’s Office, June 1 1829,” Sydney Gazette and New South Wales Advertiser (NSW: 1803 – 1842), Saturday 6 June 1829, p. 1. The Sydney Coroner at the time was Charles Thomas Smeathman who was appointed in September 1829.
 John Delhunty was appointed in January 1829 but resigned within six months. His predecessor Francis Beddek Esq had also resigned. In January 1829, prior to Delhunty’s appointment, Major Innes, the Superintendent of Police was conducting inquests in the Parramatta District.
 The doctor who appeared at most inquests in Sydney in the 1820s was the colourful colonial figure Dr William Bland.
 “Fashion of Conducting Inquests at the Parramatta Female Factory,” The Australian (Sydney, NSW: 1824 – 1848), Friday 27 November 1829, p. 2.
 “Fashion of Conducting Inquests at the Parramatta Female Factory,” The Australian (Sydney, NSW: 1824 – 1848), Friday 27 November 1829, p. 2.
 “Coroner’s Inquest Kept Private To the Editor of The Australian, Parramatta, November 17, 1829,” The Australian (Sydney, NSW: 1824 – 1848), Friday 20 November 1829, p. 3; Jeremy Bentham, “An Essay on Political Tactics: Chapter II: Of Publicity,” in John Bowring (ed.), The Works of Jeremy Bentham, Vol. II, (Edinburgh: William Tait, 1838–1843), p. 310 ; “Fashion of Conducting Inquests at the Parramatta Female Factory,” The Australian (Sydney, NSW: 1824 – 1848), Friday 27 November 1829, p. 2.
 See Ian Burney, “The Genealogy of the Popular Inquest” in his Bodies of Evidence: Medicine and the Politics of the English Inquest, 1830–1926, (Baltimore and London: John Hopkins University Press, 2000), pp. 16–51.
© Copyright Catie Gilchrist 2018