The Coroner Investigated Deaths

For over three hundred years, coroners took charge of investigating unnatural or mysterious deaths in Maryland and Delaware.  When someone raised the alarm after discovering a corpse, this county official hurried to the locality to examine the death scene, gather evidence, and figure out how the loss occurred.  Colonists brought this grim job over from England, it being a part of ancient British jurisprudence.  While the duties waned as the centuries slipped by, the coroner primarily conducted a legal and medical inquiry to determine whether the loss of life came from foul play, suicide, accident, or natural cause.((John Bouvier, in A Law Dictionary: Adapted to the Constitution and Laws of the United States of America, and of the Several States of the American Union ; with References to the Civil and Other Systems of Foreign Law, 5th ed. (Philadelphia, PA: Deacon & Peterson, 1854), pp. 317-318)) 

Adhering to the same general practices handed down over the ages, he went to where the body was discovered to take charge of the remains.  There, he checked the corpse for signs of foul play, inspected the place where it was found, interviewed witnesses, followed up on leads, and sometimes sought expert testimony.   Once he completed the initial work-up of the case, he impaneled a jury to view the body.

The Coroner’s Inquest

The inquest, a ghastly process, got underway after the jurors took a solemn oath, affirming on the Bible that they would diligently inquire into the time, cause, manner, and circumstances of the death. Pulled from their fields or shops, the hastily assembled jurors studied the corpse at the death scene, eyeballing it for wounds, bruises, or other marks of violence.  The legal requirement to “sit on the body” required a good look at the deceased, not just a quick peek, while examining it for cuts, gashes, or discoloration.  After completing the unpleasant viewing, sometimes at some of the most gruesome accidents or murders, they heard witnesses and examined other evidence.

After deliberating, the jurors rendered a verdict, ruling on whether someone was pushed, poisoned, shot, stabbed, harmed in some other way, or died of natural causes.  The inquest also sought to name the killer if the jury decided that the decedent was slain. If the panel identified a suspect, the coroner drew up a warrant and handed the case over to lawmen to arrest the suspect. 

The investigations, if appropriately done, required the know-how of a skilled homicide detective, combined with the knowledge of a physician, the judgment of a prosecuting attorney, and the wisdom of a judge. Otherwise, if the inquiry was too loose or unskillfully conducted great injustice was done.  In the ordinary run of cases, the cause was apparent, and the coroner rarely blundered.  Nevertheless, confounding cases put his fitness for the position to the test when there was a suspicion of death, but evidence of a crime was perplexing. Far too often, murders went undetected because the coroner botched the case, missing clues, failing to follow up on leads, or doing some other slipshod work.    

The Death Scene Investigator’s Appointment

It was not the most alluring appointment, nor did it lead to advancement in politics or riches.  While acceptable for the part-time nature of the post, the fee-based pay system did not make anyone wealthy.  Furthermore, the office rarely served as a stepping stone for higher political aspirations, though it was often a small plum handed out to loyal supporters of the party in power.   

Practically anyone could be chosen if they had connections.  However, their duties were occasional and unpredictable, so they had other primary occupations such as farming, merchandising, carpentry, or undertaking.  As the appointee did not need to know anything about medicine – or law for that matter — he could seek help in determining the cause of death from a physician when the cause was not apparent.

Crime Scene Investigation Advances

For centuries the coroner and his jury served an essential role in the criminal justice system. Part detective, part judge, he gathered evidence and presented it to a jury, which decided if a crime was committed and named the responsible person, if possible, in a simpler, less informed time.

However, in the twentieth century, enormous advances in medicine, forensics, police procedures, and crime scene investigations provided death investigation capabilities far beyond what untrained officeholders and their juries could provide.  The advances in medicolegal practices required highly skilled practitioners – pathologists for postmortems and the police and prosecuting attorneys to investigate crimes and handle legal matters. This was beyond the reach of this part of ancient English jurisprudence, which had once served a purpose but had become obsolete.

Instead of helping to detect a homicide and trace the criminal, this long, outdated system started hindering work that skilled specialists could do far more efficiently.  The returns from the untrained coroners and their hastily assembled juries were unreliable and often imperfect, demonstrating little understanding of the legal system or the complexities of forensics.

The Coroner Fades Away

Eventually, this ancient English institution and its inquest faded from the criminal justice system as reliance on police detectives and forensic expertise increased. The governor appointed Maryland’s coroners until 1939 when lawmakers abolished the archaic system, replacing it with qualified medical examiners.((John G. Lee, Hand-Book for Coroners: Containing a Digest of All the Laws in the Thirty-Eight States of the Union, Together with a Historical resumé, from the Earliest Period to the Present Time: A Guide to the Physician in Post-Mortem Examinations, and Valuable Miscellaneous Matter Never before Collated (Philadelphia, PA: W. Brotherhead, 1881), 248-249.))^,((Cyrus Harreld Karraker, “Qualifications and Appointments,” in The Seventeenth-Century Sheriff: A Comparative Study of the Sheriff in England and the Chesapeake Colonies, 1607-1689 (Chapel Hill: University of North Carolina Press, 2019), pp. 86-87.))^,((William R. Howell, “The Coroner,” in The Government of Kent County, Maryland: Historical and Descriptive (Chestertown, MD: Published through the cooperation of Washington College, 1931), pp. 90-92.))  But Cecil County wasn’t ready to break away from the old English office.  So, Senator C. Clyde Squire exempted the county, this old English office, which had been around since the colonial days, lingering a little longer in this corner of Maryland.((Kenney, N. T. “Coroner Bill Nearly Killed by Amendment: Four Baltimore Senators Fail in Bid to Exempt City from new Setup Like Concession to Cecil County.” The Sun (1837-), Mar 29, 1939. ))

Delaware’s governor appointed coroners at first, selecting from among two candidates nominated by popular vote in each county. But the Constitution of 1831 made it an elective post, the voters deciding. The office was abolished in 1969. That year, the Board of Post-Mortem Examiners started determining the cause of death.((“Coroner,” Delaware Public Archives – State of Delaware, December 19, 2018, https://archives.delaware.gov/delaware-agency-histories/coroner/.))^,((Chester C. Maxey, “Problems in Structure and Organization,” in County Administration in Delaware (New York, NY: Macmillan, 1919), pp. 26-28.))

It had not been the most important office, but it was a job that had to be done until advances in medicine, science, and police work made it obsolete.

For more see

The Coroner in Delaware (Under Development)

The Coroner in Cecil County (Under Development)

Pinkerton Detectives Investigated Chesapeake City Murder in 1886