Further Thoughts on Coroner’s Inquests into Deaths in Custody

Last week we cross-posted Krista Kesselring’s essay on early modern coroner’s inquests into prisoner deaths, which originally appeared on the blog Legal History Miscellany. I have never looked systematically into the records of coroner’s juries, as Professor Kesselring did, but I’ve found two intriguing cases in the course of my research that seem to confirm Kesselring’s argument about the apparent reluctance of these juries to delve deeply into the causes of prisoner deaths. The very fact that my cases come from a later period and different kinds of sources may make them of interest to readers of Kesselring’s original post.

In both of my stories, though, we not only have evidence that a coroner’s jury was negligent, but that a fuss was made about it.

The first case I want to discuss is one that I’ve blogged about before, that of the keeper of the Halstead House of Corrections, George Dewing. In February, 1728, Margaret Poulton died while in Dewing’s custody. A coroner’s jury was called, but its verdict was challenged.  As with some of the cases Kesselring discusses, the context for this challenge was political, though the players were of less grand stature. Dewing had incurred the enmity of a local justice of the peace, a Mr. Vievar.

As Dewing explained it,

The said Margaret Poulton was very sick and weak when she was committed to this said House of Correction, and was well-treated there by your Petitions, and died a Natural Death Vizt. of a consumption, and so it was found by the Coroner’s Inquest, at which the said Mr. Vievar seem’d very much displeased; and in order to inflame the  Populace against your Petitioner, and therefore prepare the way for his further Designs against him, he had no sooner performed the Burial Service for the said Margaret Poulton but he ordered her Coffin to be opened, and the Woman’s naked  and Emaciated Body be exposed for three hours together to a great Number of Spectators of both sexes, and of all Ages, to the end they might believe the said Woman had been starv’d to Death by your Petitioner[1]

The open challenge to the coroner’s jury in turn caused one of Dewing’s defenders to defend the jury as well, as having “as good a Character as any persons in the Neighborhood.” And in turn, again, all twelve members of the jury seem to have lined up behind Dewing: their signatures appear on the back of his petition, alongside those of other “Neighboring Gentleman,” presumably as supporters of his petition for mercy after her had been convicted of having murdered the infant of another inmate. The elite in this community seem to have divided into pro-Vievar/anti-Dewing and anti-Vievar/pro-Dewing factions, with the coroner’s jury falling into the latter camp. Given the string of allegations about sadistic violence to prisoners that dogged Dewing in future years, we might well suspect that the coroner’s jury neglected its job.

My second archival find is a petition presented by prisoners for debt in Newgate in December, 1724, complaining about the gaolers.

As soon as the unhappy Prisoner is dead, he or she is stript naked and carry’d  up into the upper Hall exposed to the derision of lewd felons, soon after a number of men are sent up to view the Corps by the name of the Coroners Jury who doth not allow Prisoners to be there or to be of the Jury to inform them whether the deceased dyed by famine, was murdered or whether it was by God’s visitation, but in course they report that he dyed of the Gaol Distemper, tho never so false, the Coroner never seeing or swearing the Jury super visum corporis [on the view of the body]. [2]

All of which confirms Kesselring’s suspicion that coroners did not bother to get it right, or even look at the body.

There is one interesting differences between Kesselring’s examples and the ones discussed here: in hers, the challenges to the verdicts of coroner’s inquests are tied to the presence of burning political or religious issues and are aired in the press, whereas in mine the challenges come from more plebeian sources, the Halstead crowd in one instance and the prisoners themselves in another. Is this a significant change, wherein the “public” is more ready to get involved? The history of by whom and under what circumstances the verdicts of coroner’s juries are challenged still needs to be written.

Also worth more investigation is the way in which certain attributed causes of death were taken to signify that the death was natural and no one’s fault, whereas others imply criticism of the gaoler. As Kesselring suggests, corpses that show signs of cold and hunger, of “frigore & fame,” point a finger of blame.  Perhaps that is why George Dewing was so concerned that the crowd in Halstead would see Margaret Poulter’s emaciated body. On the other hand, verdicts of death by “hectic fever,” “consumption,” “tabes,” or “gaol distemper” fell into the category of “death from natural causes, ” even though it is likely that  starvation, cold, depression or abuse made people more vulnerable to disease. The fact that “gaol distemper” was, according to the prisoners, the default verdict for negligent coroners in 1724 is especially striking. For many 18th century reformers, gaol-bred diseases often provided a central rationale for their program of regulating prisons, separating prisoners from one another, imposing cleanliness and discipline.  But the coroner’s juries that the prisoners complain about in 1724 seem uninterested in reform. What these juries meant by “gaol distemper” and why they were so quick to attribute prisoner deaths to it is an open question. Perhaps it was a convenient label for them to use because saying a prisoner died of “gaol distemper” justified the jury or coroner in spending as little time as possible in the prison. The meanings carried by different causes of death, too, have a history which we will need to understand in order to unpack the significance of what coroners say about dead prisoners.

Mostly, though, the conclusion I draw from the new material I’ve introduced here is that not much changed in the 18th century. As Kesselring concludes, investigations by coroner’s juries did more to “obscure the violence of early modern imprisonment” than to create accountability. I can’t say it better than that.

Thanks to Krista Kesselring for getting this conversation started, and for several helpful comments via email. 


[1] Humble Petition of George Dewing Keeper of the House of Corrections in Halstead in the County of Essex (with related documents). TNA SP 36/6/255 {1728]

[2] Petition of prisoners for debt in Newgate with order to Sheriffs to enquire therein. London Metropolitan Archives CLA/047/LJ/13/1724/008  [2 & 4 Dec. 1724]. Tim Hitchcock, in a comment on Kesselring’s post, points out that it was or became the norm for such juries to be made up of equal numbers of householders and prisoners.

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