THE KING'S CORONER
By W. A. BREND THE King's Coroner dates from Norman times, and the most important of his early functions was to collect certain revenues of the Crown. He took possession of the property of felons and outlaws under the law of escheat ; he assessed the value of the deodand, i.e., the thing which had caused a death and was forfeited thereby to the King ; and he held inquests on wrecks, stranded whales, royal sturgeon and treasure trove over which the Crown had rights. Of these functions, only that relating to treasure trove now remains to indicate the original purpose of the inquiry.
Thus, from the twelfth century until about a hundred years ago, the Coroner had a very definite object in holding his inquests. He was not primarily concerned with the prevention of crime or accidents, but investigated deaths simply to ascertain whether or not there were moneys which he ought to collect. These duties gradually disappeared, but no fundamental purpose was ever sub- stituted for them, with the result that the Coroner is now something of an anachronism. For modern, social purposes it is necessary to know the causes of deaths and attendant circumstances in much greater detail than was required for the simple issues of the past, but the ancient machinery of the Court has never been adapted to meet these needs. Today, causes of accidents must be studicd so that they can be prevented ; compensation is payable where death has resulted from the negligence of another ; medicine requires pathological information for scientific and statistical purposes. Clearly to discharge all these functions adequately a Coroner should be equipped in law, medicine and social science, and this is to ask too much from the nearly four hundred Coroners in England and Wales. Actually, as the new necessities arose, the practice of the Legislature has been to create special bodies for their investigation or to assign the duty to other existing tribunals.
When, for example, the network of railways began to spread over the country, the Board of Trade were given powers by successive Acts to hold inquiries into railway accidents, and this Department now also investigates disasters in mines and quarries. The Home Office inquires into accidents or poisoning in factories ; and the Ministry of Health is empowered to study epidemics of food-poisoning or disease. Compensation for death from accident or negligence, if the claim is disputed, must be determined in the County Court or High Court, where probably the inquest verdict will never be mentioned. The investigation of suspected murder or manslaughter is essentially a matter for the Police and Magistrates, the Coroner acting strictly in conjunction with them when holding the inquest. Thus for most of the important pur- poses for which society requires to know the attendant circumstances of a death, the investigation is made by other tribunals. The present system involves con- siderable overlapping, waste of Juries' time and often the returning of a verdict which serves no useful purpose. The annual cost of the Coroners' service is about £220,000, and it is not clear that the community is getting adequate return for this expenditure. It is in relation to inquiries demanding medical or scientific knowledge that the inquest most needs strength- ening, for the purely legal issues are already adequately covered by other Courts. Medical points arise in almost every case and in many—where the question of violence is not necessarily in issue—the determination of the pathological cause of death is important for scientific purposes, yet the Coroner is not required to be a medical man. This is a handicap which is not compensated for by any amount of legal erudition, and is particulurly likely to be felt in those preliminary inquiries which a Coroner must make before deciding whether or not to hold an inquest. In 1931, the latest year for which statistics are available, 62,082 deaths were reported to the Coroners in England and Wales, and in 27,358 of these, after investiga- tion by the Coroner, no inquest was held ; yet in only 8,458 of the latter was a post-mortem examination made. As inquests must be held on all deaths from violence, presumably the great bulk of the non-inquest cases were deaths reported by doctors, in which violence was not suggested but the pathological cause of death was un- known. This means that in a number of cases a medical issue must have been determined by a non-medical Coroner without expert medical advice, and without an examination after death, on the report from a person himself concerned in the circumstances.
Many forms of accidental deaths could be more thoroughly investigated if time Coroners had greater facili- ties for employing expert or technical assistance, par- ticularly in those classes of accidents which do not already fall within the purview of a Government Department. Nor is it clear that full use is made of the information which is collected. It is a significant fact that although motor vehicles have been on the roads for more than 30 years, and many thousands of inquests have been held on deaths in street accidents, we are nevertheless told that there is still much uncertainty as to the essential causes of these accidents and time best means of preventing them.
One form of death has yet to be mentioned. A more merciful age sees in the suicide a sick man rather than a criminal, and there can be no doubt that the great majority of these unhappy people arc mentally dis- ordered. A public inquiry is rarely necessary in order to elicit the relevant facts, and is a trying ordeal for the relatives. Private matters arc apt to be brought out in Court without serving any useful, public purpose, and letters, written in despair, may be read, bringing charges, often imaginary or exaggerated, which merely serve the purpose of the sensational journalist. Some Coroners consider it is part of their duty in these circumstances to pass censure upon persons concerned or to express opinions on questions of morality. But the real facts in these painful cases are often not fully ascertained, and the conventional attitude may lead to a harsh judgement. As long as the Police and relatives have full right of entry, there seems no reason why these inquiries should not be held in private, following the more humane practice which prevails in Scotland and France.
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