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Death By Misadventure: Coroners' Inquests 1700-1850 - Part 1

1978

This is a slightly modified version of the original article which appeared in Vol 2 of the Stamford Historian, published in 1978.  In addition to the appendix below, published with the original article, further examples of the contents of Coroners’ Files will be added elsewhere on this website.

 

DEATH BY MISADVENTURE: CORONERS’ INQUESTS, 1700-1850
 
BACKGROUND
Among sources often neglected by the local historian are the papers of Coroners’ Inquests.  Studies of the work of the medieval coroner have been made[1] and collections of documents published[2], but very little use has been made of inquest papers of the eighteenth and nineteenth centuries. It may well be that they have been neglected because few have survived and their usefulness has not therefore been brought to general notice.
 
It must be confessed at the outset that the papers often make depressing reading. Few can find much pleasure in detailed accounts of the deaths of suicides or of young children killed by negligence. However the papers of an inquest provide information which cannot easily be found elsewhere. While other sources, particularly newspapers, may provide some information, it is rare that they contain the richness of detail to be found in evidence given by witnesses at inquests. Moreover the evidence of witnesses often gives the modern historian an insight into the lives of the poor, rather different from that which is given by other sources.  Something of this is apparent from the examples cited from the surviving inquests relating to the borough of Stamford.
 
Stamford has a collection of over three hundred inquisitions dated between 1705 and 1850. More than half these official reports of the findings of the coroners’ juries have the evidence of witnesses preserved with them. These three hundred are the surviving ones; many more must have been lost, and it is not therefore possible to attempt more than a general survey of their findings.
 
The Coroner
The office of Coroner was well established by the early years of Edward I’s reign, and his duties were clearly defined soon after this. In Stamford, until 1835, the office of Coroner was held by each retiring mayor in turn[3]. Along with his other duties (including inquests for treasure trove and similar investigations) the Coroner was ordered to hold an inquest whenever an unexpected or unnatural death occurred within his jurisdiction. It was an offence to fail to inform him of a death which came into this category, as it was to bury the body before the inquest had been held. The Parish Constable was ordered to provide a jury of at least twelve men (no upper limit was set) who had to appear unless they had a ‘reasonable excuse to the contrary’. The jury had to take the inquest ‘upon view of the body’, and no inquest could be held unless the body had been seen by the jury in the presence of the Coroner. The notorious inquest at Oldham, Lancashire, in 1819 on John Lees who died from injuries received at Peterloo, was never completed for this reason. It was the duty of the jury to find out what had happened, and to present a verdict to the Coroner. rather than to hear a case presented by a prosecution. The many questions which the jury had to ask were established by law. Detailed descriptions of wounds had to be made and these feature in almost all records of inquests[4].
 
The Verdict
The decision reached by the jury about the cause of death was normally very clearly indicated on the inquisition, the signed and sealed report of the jury.  Murder, manslaughter, accident and natural causes (‘the visitation of God’) are usually stated quite plainly, but one finds less uniformity in cases of suicide. The jury may give an explanation why a person took his own life; for instance, some physical defect may have brought somebody to the brink of insanity; but often no explanation is given. The distinction between temporary and permanent insanity is not always made. Thus when William Venters of Stamford threw himself from the town bridge in November 1827, the verdict returned was suicide through lunacy, in spite of the evidence that he had been drinking quietly, though in a depressed state, at the Queen’s Head Inn.  About ten o’clock in the evening his wife, ‘a woman not bearing a very good character’, entered the Inn and started ‘soliciting his return home’; one is probably safe in assuming that it was her nagging that drove him to his death[5]. Other qualifications to the verdict of ‘suicide’ were sometimes returned, and open verdicts were given in a number of cases of drowning and infant mortality.
 
The Records of Coroners’ Inquests
The records of inquests of the eighteenth and nineteenth centuries usually contain three sets of papers. The first is the ‘Inquisition Indented’, so-called from the opening words of the official report. This has the general details of the finding of the jury, and may give a brief account of the events leading up to death when these can be ascertained. Secondly, many collections have statements of evidence, sworn before the Coroner, on which the jury based its decision. Some witnesses’ evidence was slight and it may be reported verbatim in the Inquisition; but in other cases, particularly the later ones, the evidence is much more substantial. In drownings and similar tragedies short recent biographies of the deceased may be given so that the jury could establish whether the death was an accident or suicide.  Doctors’ evidence appears in most instances, whether to establish the cause of a natural death, often a hit-or-miss affair, or to report on the care of a person between accident and death. Workmates say what they know of an accident; travellers report on the state of health of a fellow passenger or the competence of a coach driver. From such evidence, much may be discovered. What may have been irrelevant to the Jury then, and therefore not mentioned in the Inquisition, may provide a valuable insight for the historian now.
 
In addition to the Inquisition and the evidence of the witnesses, other papers may well survive among Coroners’ records. Lists of the jury were drafted before they were summoned to appear; the costs of witnesses were recorded; orders were made to hold persons who might have to face criminal charges when manslaughter or murder had been found to be the cause of death. If an inquest were held on somebody who had died in gaol, very thorough investigations were made, and these papers may be preserved with the other records.  Included in one set of papers are the notes of a Stamford Coroner about suicide and how it should be regarded, while in another set is the original suicide note from a woman to her brother[6].
 
Other Sources
It is often possible to gather further information about a case by recourse to other sources. Quarter Sessions Rolls may contain relevant material; Assize Courts dealt with murder cases and their records may complete the story of an inquest; parish registers may mention the burial of someone who died accidentally, with a note to indicate this. In the later eighteenth century, and for the whole of the nineteenth century, the local newspaper is a source which should be consulted in order to fill out the picture, though often it may add little, especially when the evidence of the witnesses is detailed or when, as increasingly became the case, the newspaper reported the inquest itself rather than relating the story independently.  If the victim had been of importance in the local community a short obituary may have appeared.
 
THE STAMFORD INQUESTS
Few places possess a substantial collection of original Coroners’ Inquisitions with their subsidiary papers, and those that have survived at Stamford are most interesting. Their value is enhanced by the fact that for most of the eighteenth century we have the Stamford Mercury, while during the early nineteenth century as many as four local newspapers were published, copies of which survive.
 
Murder and Manslaughter
Only a few inquisitions at Stamford found murder to have been the cause of death. This is partly because all official papers had to be forwarded to the Assizes and it was not customary for copies to be kept locally. Of the five murders whose records survive among the Stamford Inquisitions, only one deserves a mention. In 1782 a quarrel between two victuallers in the town led to the death of Robert Osborne, master of the Black Swan.  William Fawkner was held in gaol to answer for the offence. It appears that Osborne had been obstinate and had refused to give up a quarrel, in spite of pleas from his friends. The Mercury (28 Feb. 1782) reported that “the heartfelt grief of Mr. Osborne’s antagonist cannot be expressed, tho’ the nearest of his friends do not blame the person he fought with for this misfortune”.
 
Manslaughter also seems to have been relatively rare, though this may again be due to gaps in the records. We know most about a case involving Richard Facon who made a visit to a ‘female acquaintance’ at Tolethorpe, about two miles from Stamford, in 1774. She was not at home so he went to the house of a friend of his, the miller Mr. Goodwin, thinking she might be there. He peered through a window but could not see her. However one of Mr. Goodwin’s servants saw the face looking in and told his master. Goodwin, who had been robbed a few months earlier, went after Facon, shot first and then asked questions. Facon’s hand was ‘shattered in a most miserable manner’ (Mercury, 22 Dec. 1774) and Goodwin did not realise that he had hit an ‘intimate acquaintance and very good friend’ until after he had further injured him with the butt of his gun. Facon was taken back to Stamford where he died some days later. Though the accident took place outside the Stamford Coroner’s jurisdiction, it was usual for the Coroner of the place where the death eventually occurred to hear the inquest.
 
Suicide
            Suicides seem to have been fairly frequent. Stress and strain are not modern phenomena, as the evidence in many cases makes clear. Methods varied greatly and they are often described in detail. Two cases of suicide by shooting occur; some cut their throats, but no records survive to show cutting of wrists as the cause of death. Hanging and drowning were most common of all. Juries had to be satisfied that a drowned person had intended to take his own life, and so the detail of the witnesses’ evidence is often considerable. ‘Gibraltar Pitt’ in the town meadows seems to have been a most dangerous place, since swimmers drowned there, as well as its having been the site of at least one suicide. An inmate of Browne’s Hospital, a medieval almshouse, Francis Allen aged eighty two, put his head in a butt of water while troubled by a painful hernia, and a verdict of ‘delerium and despondency’ leading to suicide was returned. Others chose poisons: mercury, opium and even a ‘sublimate’ for treating venereal disease, but laudanum seems to have been especially favoured.
 
Natural Causes
            Many deaths were, of course, attributed to natural causes, and one can often see in the medical evidence at these inquests an attempt by the doctors to get to grips with pathology. Many deaths are recorded as ‘from apoplexy’ and left at that. Some cases were however clear for all to see. Jane, the wife of John Chamberlain White, met her end according to the jury through too much ‘drinking of ardent spirits’, and there is the evidence of various witnesses to show that she had been in the habit of ‘drinking large quantities of spirits of lavender, spirits of wine, and other stimulants’ (Mercury, 11 Mar 1831). Equally simple for the doctors to decide was the case of William Fletcher who died in the winter of 1800 through the ‘natural causes’ of starvation, illness and infirmity.
 
The medical profession, and the Coroners’ juries, faced their stiffest test when confronted with the body of a very young child. It was often impossible to get any other evidence than the mother’s and this might be suspect. Thus ‘open’ verdicts may be returned in cases of this kind. But a jury in 1840 found that a new born female child of Frances Palmer, a widow, had died from ‘natural causes accelerated by improper treatment’. Perhaps the most perplexing case of all, both to the jury then and the reader today, was that of a ‘male infant child’ found dead in 1827. On the Inquisition its age is given as five days, yet at the inquest the jury returned the verdict of ‘stillborn’. With the Inquisition is a thick sheaf of papers containing evidence and the supposed mother, Elizabeth Cunnlngton, was held in custody by the Magistrates for inquiries to be made.
 
Accidents at Home
            Not surprisingly poisons were also a common source of accidents in the home. In several cases laudanum, used by parents as an opiate to keep their children quiet, was accidentally administered. Edward Alexander, aged fourteen weeks, was given laudanum instead of children’s cordial in 1834, while James Addleshaw, a victualler, was given the same by mistake instead of tincture of Rhubarb. Samuel Spencer’s mother also intended to give her son tincture of Rhubarb but instead gave the three week old baby oil of vitriol (sulphuric acid). She realised her mistake immediately, but the doctors could do nothing to help the child. Other accidents in the home were quite common, especially to the very young or old. There are a number of cases of clothes catching fire, while dangerous cellar steps at Truesdale’s Hospital led to one death.
 
Accidents at Work
            Work was always accompanied by hazards. On the last day of December 1795 the Coroner’s jury ‘sat on the body’ of Thomas Wing, aged eleven, who had fallen into the Welland the previous day and drowned. He had been fetching water for a forge nearby owned by his master, Thomas Harper. The Mercury (1 Jan. 1796) carried a report of the accident and criticised his parents: ‘his tender (sic) parents were soon apprised of the circumstance (singular we hope it.) His body was left to cool in the river till the next morning.’ Even a simple task like washing out a cart could be dangerous.  Edward Jackson was drowned in a patch of deep water in the Welland when his cart went out of control.
 
Not surprisingly the accidents at work were very varied. Richard Sandall fell from a ladder when a rung broke; Richard Scholes fell from a haystack he was making onto the upturned prongs of a pitchfork. At W. B. Edwards’ brewery at least one of two accidents was caused by intoxication.  While Francis Cole was emptying hops into the boiling copper he fell in and was scalded very severely, but he survived long enough to make the uncomfortable journey in a jolting cart the half mile from the brewery to his home where he died eight hours later.  Six years after this, in 1832, John Andrews did not take proper precautions, according to his workmate Ambrose Ripping, before going into a vat to clear out the dregs of the stale ale and he was suffocated by the gases that remained. It took several attempts by the foreman, Joseph Wilson, before he could stay long enough to attach a rope to Andrews’ leg (Mercury, 5 Jan 1832). Abraham Ryley was knocked from the staging of Mr. Brown’s bark mill in 1813. It seems likely that a gust of wind started the mill sails unexpectedly.  The force of the sails was such that he was thrown over some buildings, across a road and into a paddock.  He left a widow and seven children, five of them under eleven, for whom the Mayor and the owner of the Mercury started a subscription (Mercury, Aug. 1813). A similar accident had happened to Alice Wilson in 1745. At Hudd’s Mill in 1814 Job Topley, ‘an industrious man in the employ of Mr. Smith, miller’ (Mercury, 28 Jan.) was standing on the water wheel clearing ice when it suddenly started, crushing him and nearly killing Stephen White, his helper, who gave detailed evidence at the Inquest.
 
Although the range and variety of accidents is very great, certain trades were rather more dangerous than others.  In spite of the incompleteness of the inquest papers it is possible to suggest that the most dangerous occupations were those connected with building and transport.
 
The Building Trades seem to have had many accidents, involving most of the separate occupations within the trade.  Unsurprisingly, stone quarrying was very dangerous and there are several inquests on people like Christopher Wilson and William Peasgood, both killed in 1818 when there was a rock fall in a stone pit. Once the stone had been won, other risks arose.  Ladders and scaffolding caused accidents - Robert Pilkington, a member of a well-known Stamford family of builders, fell from a ladder in 1825 while the Gas Works was being made. Though the collapse of St. Michael’s Church in 1832 was not attended by any fatalities, repairs on churches were always dangerous. In 1788 Robert Shaw was working on the steeple of St. Mary’s Church when the rope of a basket used for lifting stone caught on one of the crockets of the spire and this fell on him; a ‘Charitable Card Assembly’ (the eighteenth century equivalent of a whist drive) was held for the benefit of his widow and her six children, and over £26 was raised (Mercury, 29 Aug., 5 Sept. 1788). Surprisingly, only one death of a slater is recorded, perhaps because the job was obviously dangerous and more precautions were taken. In 1811 Thomas Jorden was working on the house of the Rev. John Butt at and though others were at work there, nobody saw him fall.   It was reported that he was subject to fits and it is possible that this was the cause of his mishap. Another member of the same family, Joseph Jorden, had been killed in 1786 while making alterations to a house when an arch collapsed on him.  Finally there was the case of Thomas Pierce, an architect who was responsible for work at the Stamford Hotel Cockpit in 1825. He was found dying by his own workmen at the foot of some stairs.
 
If building was a dangerous occupation, transport in one form or another seems to have accounted for the largest number of accidental deaths.  Cases were recorded, much as one might find today, of children run over - Charles Hudson was playing with a ball when he was hit by a cart; in 1793 Thomas Jackson, aged four, was run over; most tragic of all was the death of Mary Ann North, also aged four, who was run over by the cart her father was driving.
 
Innocent pedestrians might suffer as well as careless children. Thomas Thompson, aged about eighty, called to a carter to beware of some holes at the side of Red Lion Square, a section of the Great North road. Whether the carter heard or not, the wheels of the waggon fell into the holes and the cart shed its load of elm tree trunks over the pavement and over Thompson. A stationary wagon was not necessarily safe either - William Olphin, nine, was playing with his friends near a cart, when its load of pipeclay fell over him. Whether he or one of his friends caused the cart to tip up was not proved satisfactorily, though the owner of the cart assured the jury that it was the fault of the children rather than negligence on his part that caused the accident. According to the Mercury (10 Jan. 1823) Olphin was in the act of removing the support of the cart when the load fell on him. Richard Pitt’s death in 1776 reminds us of the dangers for the pedestrian in winter journeys. He died, accidentally, so we are told, while travelling from Oakham to Stamford in cold, snowy weather.
 
During the period between 1770 and 1840 several travellers along the Great North Road gave evidence to inquests that they had found a cart or wagon stationary beside the road without any driver. Further along the road they had found the driver dead, more often than not run over by the wheels ofhis own wagon. In some cases medical reasons were adduced for the prior death of the driver, but more frequently the evidence was that the driver had fallen from his bench, perhaps while drunk. It would appear that many carters tended to take advantage of the facilities which main streets in Stamford offered to the thirsty. Occasionally a coach, chaise or cart overturned, or the horses bolted, with fatal results to drivers or riders. In 1839 John Clarke tried to climb onto the Wonder coach as it left up the long hill from Duddington, about five miles from Stamford, to get a free ride into town, but he fell and his legs became entangled with a wheel. He was taken to the Stamford Infirmary but his injuries were too severe for him to survive. Even the arched entry to a yard could be dangerous; in 1729 Thomas Blain tried to drive a coach into Henry Dove’s yard but the archway was too low and he was crushed to death.
 
Those looking after horses were also at risk - kicks from horses while they were being groomed proved fatal in a number of cases. In another instance a lad aged thirteen, George Waterfield had, without permission, taken a horse out of a stable to graze. He lay down and slept, having first fastened his arm round the halter of the horse in such a way as to prevent its escaping from him. Something made the horse bolt, and Waterfield was dragged through the town. ‘When the body was disengaged’, the Mercury reported (18 July 1811), ‘It was in a state too shocking to describe’; nevertheless the account did continue: - ‘the upper part of the head had been literally beaten off against a stone’.
 
The river seems to have been a much safer place for those earning their living. Only one person was reported as having drowned in a fall from a boat, though another was drowned while helping to build the town bridge in 1848. While some inquest papers must have been lost it would seem significant that none refer to people being killed while following a waterborne trade, in spite of the fact that many boats came up the Welland and the Stamford Canal during the period under review.
 
By contrast the building of the railway between Stamford and Collyweston in 1847 led to four deaths in seven months with two more the following year.  One man died during blasting operations when rocks fell on his head; two more were killed by falls of soil while undermining for cuttings; the other three were run over by horse drawn railway waggons removing spoil from cuttings to places where embankments were being made.
 
In Stamford in January 1847, only a fortnight after direct railway communication with London had been established, James Bowley died as a result of an accident in the engine shed.  Bowley was employed lighting fires and preparing engines for the early morning trains, a job which entailed arrival at work at about four o’clock in the morning every day. Unfortunately the train due in from London at 10.30 p.m. on 21st January had arrived about five hours late and though its engine, No. 122, had been raked out there was still steam left in the boiler. By all accounts given to the inquest, Bowley went between the buffers of this engine and another, No. 17, to uncouple them, and thus broke the rule of his Company (as the Superintendent of the coaching department of the Eastern Counties Railway was quick to point out) by not ducking under them. As he went between the engines, No. 122 moved slightly and he was trapped and crushed. However he did not die until six days later and was able to give his own version of the accident. This has been preserved among the inquest papers. According to Bowley, Charles Mitchell, a sixteen year old who was employed to clean the engines, “was on the tender of No. 122 shifting the rods, and I told him to leave off doing so and come off the engine.” Bowley claimed that Mitchell was “a bad boy and always full of mischief. I have frequently told him to leave the Engines alone as he has no business to touch them, he was very impudent to me, and I should have reported him .... but was afraid he might lose his situation.” Mitchell was questioned very closely by the jury, and his evidence tells rather a different story. “He instructed me to get on the Engine 122 and to put her back to the other engine No. 17 . . . I put her in motion but a little bit. . . .“ The Mercury report (29 Jan. 1847) which was published during the inquest, since an adjournment was made for a post mortem to be held, was unequivocal - it was Mitchell’s fault, they said. However, the jury found no evidence to suggest manslaughter and decided that since Bowley had broken Company Regulations, his death must be attributed to accident.
 
This case has been dealt with at length to show something of the detail which inquest papers may contain. Other information which emerges from the evidence includes the report that Bowley and Mitchell were the only ones in the shed at the time of the accident, two other workmen having gone to the Exeter Arms, whether for breakfast or for a drink we do not know - and this at 4.30 a.m. In addition Mitchell’s hours of work and wages are specified; 4 a.m. to 4 p.m. and a quarter of an hour each evening with some occasional extra duties for 10/6 (52½p) a week.
 
Leisure
            One final group of inquests remains to be mentioned. Many leisure activities also had their dangers. One must interpret the term ‘leisure’ very loosely, since an evening’s drinking must fit this description. On 30 May 1791 Charles Myers spent the day drinking with his cousin, and in the evening he went alone to the Bull Inn. They refused to serve him there and gave him a chair in the kitchen so that he might sleep off the alcohol, but later he awoke and was taken upstairs to a first floor room. He had a dream, so he told the doctor who attended him after his accident, that his cousin was leaving the Inn by the main gate, and he thought he would climb from the window to stop him, having no memory of being taken upstairs. In his consequent fall he fractured his thigh and died outside the Inn about an hour later. Many other fatalities, including falls from haylofts and down cellar steps of inns, occurred as a result of drunkenness.
 
During winter, skating was always a popular activity and in 1814 William Freeman fell through the ice on a pond at Burghley House.  According to the Mercury (4 Mar. 1814) the “weather and the ice afforded a warning of danger” but Freeman took no notice. Only one person saw him fall in, and though he was able to cling on for twenty minutes no help arrived for him in that time. It was said that the witness was unable to convince any of the people standing on Burghley Bridge that he was not hoaxing them. During the summer, when swimming in the Welland was popular, a number of drownings happened, either in the river itself or in the ponds which were then in the meadows.
 
Among the inquests only one records a fatal accident as a result of the annual Bull Running in November, though another death as a result of being tossed by a bull occurred in January 1728.  In 1801 Benjamin Overton, a horse keeper aged twenty-six, followed the bull on Bull Running day into the Welland. By all accounts he was very drunk at the time and most thought that the death was caused by the sudden shock of the cold water.  Overton’s death is mentioned in the burial register of St. George’s parish with the simple comment ‘drowned on Bull Running day’.
 
One other unclassifiable case deserves a mention. On 31 March 1802 William Reisby (or Reesby) aged fourteen had joined with many others in celebrating the Peace of Amiens. The news of the Treaty had reached Stamford the previous day and the Mercury published a special single page edition to announce that Napoleon’s France had agreed a peace with Britain. Though the Treaty lasted for no more than a year, it was thought at the time that it really would be the end of the war, and thus it was celebrated extravagantly throughout England. The Mercury (2 Apr. 1802) tells us that “the general mirth was unfortunately interrupted during the firing of the military in the Hay Market by the accidental discharge of a small piece of ordnance while loading, by which we are concerned to say a son of Mr. Reesby, baker in Scotgate had his head blown to pieces”. The Coroner’s inquest papers make it clear why the accident was so terrible; at the time the cannon went off the ramrod was still in the barrel, and it was this that hit William Reisby on the side of the head.
 
If Reisby’s death is one of the most bizarre of all those that occurred and whose records have survived for us to read about in detail, it does nevertheless illustrate something of the richness of Coroners’ inquests as a source for the local historian.  They can provide useful illustrations and examples for many different studies.
 
 
 
APPENDIX
This Inquisition with its sworn evidence is fairly typical of those that have survived at Stamford. It has been chosen because it shows a parish officer, the Beadle of St. Martin’s, showing little humanity as he ensures that his parish will not become liable for any costs associated with the traveller by forcibly removing him to the next door parish; in addition it is interesting to find a reference to a sedan chair carrier at work at this late date. Until 1835 St Martin’s parish, south of the river Welland came under the civil and ecclesiastical jurisdiction of Peterborough while north of the river the five parishes owed their allegiance to Lincoln; the town’s magistrates were ultimately responsible for all aspects of local government north of the river.  In addition, until 1832, Stamford voted for two members of Parliament while St Martin’s householders voted in Northamptonshire. 
 
FORMAL VERDICT OF THE INQUEST
The Town or Borough of                       An Inquisition indented and taken for
STA MFORD                                        our Lord the King within the Borough
                                                          aforesaid, on Saturday the Twenty
In the County of Lincoln.                       fifth Day of October in the ninth Year
                                                          of the Reign of our Sovereign Lord
George the Fourth by the Grace of God of the United Kingdom of Great Britain and Ireland King, Defender of the Faith, and in the Year of our Lord One Thousand Eight Hundred and twenty eight before Matthew Rooe Esquire, Coroner of our said Lord the King in and for the said Borough, on View of the Body of a person unknown aged about Twenty Years, then and there lying dead, by the Oath of Thomas Peatling, John Abbott, William Chambers, William Cox, Daniel Whitehead, Francis Coy, Joseph Tomlinson, Samuel Lightfoot, Thomas Bainton, William Barton Parker, William Dawson the younger, William Lowson and Elijah Dixon, good and lawful Men of the said Borough, duly chosen, and who, being then and there duly sworn and charged to inquire, for our said Lord the King, when, how, and by what Means the said person unknown came to his Death, Do upon their Oath say, That on Tuesday last between five and six o’clock the deceased who said he was an Irishman was seen in this Borough in an ill state of Health being an entire stranger, that the next morning Wednesday he was found very ill and nearly exhausted, that in consequence he was taken to the Workhouse in the Parish of St. George in the said Borough where he languished for a short space of time and then and there died by the visitation of God in a natural way and so the jurors aforesaid upon their Oath aforesaid do say that the said deceased came to his death in manner aforesaid by the visitation of God in a natural way and not otherwise. In witness whereof as well the said Coroner as the Jurors aforesaid have to this Inquisition set their hands and seals the day and year first above written.
 (Signature of N. Rooe, Coroner with seal of the Borough of Stamford, and signatures and blank seals of thirteen jurors.)
 
SWORN EVIDENCE TO THE INQUEST
The Town or Borough of                       Informations of Witnesses severally
STAMFORD                                         taken upon Oath, within the Borough
In the County of Lincoln                        aforesaid, on Behalf of our Lord the
                                                          King touching the Death of a person
                                                          unknown aged about Twenty Years, on
Saturday the Twenty fifth Day of October in the ninth Year of the Reign of our Sovereign Lord George the Fourth by the Grace of God of the United Kingdom of Great Britain and Ireland King, Defender of the Faith, and in the Year of our Lord One Thousand Eight Hundred and twenty eight before Matthew Rooe Esquire, Coroner of our said Lord the King in and for the said Borough, on an Inquisition then and there taken on View of the Body of the said person unknown then and there lying dead.
 
John Arden of the said Borough, mason, sworn saith that on Tuesday last between five and six o’clock In the evening he was going into Saint Martin’s over Stamford Bridge and near to the end of the Bridge on the Stamford side he saw the deceased who appeared to be very ill and that William Scuithorpe the Beadle of Saint Martin’s was with him and shoving or forcing, him along over the Bridge into Stamford, that deceased declared himself to be very ill several times and the said Sculthorpe said he was drunk, that the said Sculthorpe shoved the deceased down and he fell upon his face on the Ground when the said Sculthorpe said I have done with you now (meaning the deceased) I have got you clean out of the Parish, that this Deponent being employed in carrying a sedan chair passed on and does not know what further took place at that time. That the next morning this Deponent being near to Mr. Lincoln’s back gate about half past six o’clock saw the deceased walking very slowly with his dress in a disordered state and he then seemed to be very ill.
                                              John Arden        X his mark
 
William Hudson, Tanner, sworn, saith that about six o’clock  on Wednesday morning last on going into the Bark Mill upon Mr. Stevenson’s Premises he found the deceased lying on his back with his head hanging over a Basket and his Hat off, that he seemed to be in an intoxicated state and to have been there all night, that this Deponent removed him from the premises and he walked a little way and wanted to come back again but this Deponent told him he could not be allowed to do so, that he could scarcely speak but mentioned his name which this Deponent has forgotten and he said he was an Irishman - that about eight o’clock this Deponent again saw the Deceased under the Gas Wall and he seemed then to be in a state of exhaustion or intoxication which this Deponent did not know.
                                          William Hudson      X his mark
 
Leonard Stevenson, Surgeon, sworn Saith that on Wednesday morning last about seven o’clock he saw the deceased walking in a staggering way towards the Gas Wall, that when near it he turned about and stood fumbling with his hands with his Hat over his face and this Deponent thought he was tipsy but did not take further notice of him - That about an hour afterwards he was sent for to attend a person in Saint George’s Workhouse whom he found to be the deceased who had been taken there and put to bed - that on examination this Deponent found the deceased to be nearly exhausted and in a dying state - that he directed some food and cordials to be immediately given to him neither of which he could take and upon the whole this Deponent thinks that the deceased came to his death from (‘want and’ crossed out) exhaustion and from no other cause.
                                       Leo. Stevenson     Surgeon
 
Taken and sworn before me
        M.  Rooe       Coroner.
 

 
 
[1]R. F. Hunnisett, The Medieval Coroner, Cambridge 1961, and references cited there.  See also Coroners’ Records in England and Wales, J Gibson & C Rogers 3rd Edn., Bury, Lancs; Family History Partnership, 2009 which gives a guide about the availability of records but little about their contents or uses.
[2]Notably Thoroton Society, Record Series, XXV for 1966, Calendar of Nottinghamshire Coroners’ Inquests, 1485-1558, ed. R. F. Hunnisett; also The Earliest Lincoinshire Assize Rolls, 1202 -1209, ed. D. M. Stenton, Linc. Rec. Soc. XXII.
[3] G. Burton, Chronology of Stamford, Stamford 1846, p. 116.
[4] Any edition of the eighteenth- and early nineteenth-century handbook for magistrates, The Justice of the Peace and Parish Officer by Richard Burn, will provide information about the method of holding an inquest. It gives the wording of all the forms and the various technical and legal terms which were used in inquests.
[5] The Stamford Coroners’ papers are at present (2012) stored in the Town Hall. It is possible to find an individual Inquisition quite quickly from the contemporary endorsement though currently these records are not available for consultation [See note to List of Inquests]. Newspaper references have generally been given when quoted.
[6] Coroner’s comments on suicide in papers for inquest on Mary Ann Black, 17 July 1810; suicide letter in papers for inquest on Jane Congreve, 22 June 1842.