Fundamentally, this is not so different from the way a homicide is handled in England today, except that a coroner's court would hold an inquest at the conclusion of the scene investigation and examination of the body. Information and witnesses would be marshalled before the coroner and a jury, and a decision would be rendered by verdict as to whether the death was natural, an accident, a suicide, or a homicide. In Virginia, the manner of death would be the sole decision of the forensic pathologist who performed the autopsy. In England, the decision would rely on jurors, which can be unfortunate if a majority of them don't comprehend the medico-legal facts of the case, especially if those facts are weak.
However, jurors can go a step further than the forensic pathologist and commit an "undetermined" case to trial. I think of the case of a "drowned" woman whose husband has just taken out a large life insurance policy on her. The medical expert's job is not to make deductions, no matter what he or she privately believes. But jurors can. Jurors could convene in their private room and suspect the woman was murdered by her greedy husband and send the case to court.
The American way of investigating death was imported from England. But over the decades, individual U.S. states, counties, and cities have slowly been withdrawing from the notion of the "coroner," who is usually a nonmedical person elected and invested with the power to decide how someone died and whether a crime was committed. When I first began working at the Office of the Chief Medical Examiner in Richmond, I assumed that other jurisdictions had the same medical examiner system that Virginia did. I was dismayed to learn this wasn't true. Many elected coroners in other states were funeral home directors, which at best is a conflict of interest. At worst, it is an occasion for medico-legal incompetence and the financial abuse of people who are grieving.
The U.S. has never had a national standard of death investigation, and we are far from it now. Some cities or states continue to have elected coroners who go to the scenes but do not perform the autopsies because they are not forensic pathologists or even physicians. There are offices - such as the one in Los Angeles - in which the chief medical examiner is called a coroner, even though he isn't elected and is a forensic pathologist.
Then there are states that have medical examiners in some cities and coroners in others. Some locales have neither, and local government be-grudgingly pays a small fee for what I call a "circuit forensic pathologist" to ride in and handle a medico-legal case, usually in an inadequate - if not appalling - location such as a funeral home. The worst facility I remember was one in Pennsylvania. The autopsy was performed in a hospital "morgue" used as a temporary storage room for stillborn infants and amputated body parts.
Chapter Thirteen. Hue And Cry
The English system of investigating death can be traced back some eight hundred years to the reign of Richard I, when it was decreed that in every county of His Majesty's realm, officers would insure the "pleas of the crown." These men were called "crowners," a name that eventually evolved into "coroner."
Coroners were elected by the freeholders of the county and were required to be a knight, assuring they were financially secure, of good standing, and, of course, objective and honest in their collection of revenues due to the crown. A sudden death was a potential source of income for the king if there was a finding of wrongdoing in murders and suicides, or even if there was an inappropriate response by the one who discovered the dead body - such as not responding at all and looking the other way.
It is human nature to make a hue and cry when one stumbles upon a dead body, but during the medieval era, not to do so was to risk punishment and financial penalty. When a person died suddenly, the coroner was to be notified immediately. He would respond as quickly as he could and assemble a jury for what would later be called an inquest. It is frightening to consider how many deaths were labeled evil deeds when the truth may have been that the poor soul simply choked on his mutton, had a stroke, or dropped dead at a young age from a congenitally bad heart or an aneurysm. Suicides and homicides were sins against God and the King. If a person took his or her own life or someone else did, the coroner and jury determined wrongdoing by the deceased or perpetrator, and the offender's entire estate could end up in the crown's coffers. This placed the coroner in a tempting position to perhaps bargain a bit and show a little compassion before riding off with coins jingling in his pockets.
Eventually, the coroner's power placed him in a seat of judgment and he became an enforcer of the law. Suspects seeking refuge in the church would soon enough find themselves face-to-face with the coroner, who would demand a confession and arrange the seizure of the man's assets in the name of the crown. Coroners were involved in the gruesome practice of trial by ordeal, requiring a person to prove innocence by showing no pain or injury after holding a hand in the fire or enduring other dreadful tortures while the coroner sat nearby and somberly watched. Before the days of medico-legal autopsies and professional police investigation, a wife's tumble down the castle steps might be murder if her husband could not endure terrible tortures and escape unscathed.
Coroners of old were the equivalent of today's forensic pathologist having no medical training and driving a morgue van to a death scene, glancing at the body, listening to witnesses, finding out how much the dead person is worth, deciding that a sudden death from a bee sting was a homicidal poisoning, testing the wife's innocence by holding her head under water, and if she didn't drown after five or ten minutes, concluding she was innocent. If she drowned, wrongdoing was the verdict and the family estate was forfeited to the Queen or the president of the United States, depending on where the death occurred. In the coroner system of days gone by, jurors could be bribed. Coroners could increase their wealth. Innocent people could lose everything they owned or be hanged. It was best not to die suddenly, if possible.
Times did change for the better. In the sixteenth century, the coroner's role narrowed its focus to the investigation of sudden deaths and stayed clear of law enforcement and trial by ordeal. In 1860 - the year Walter Sickert was born - a committee recommended that the election process for coroner be treated as seriously as voting for Members of Parliament. A growing awareness of the importance of competent postmortem examinations and handling of evidence added further value and prestige to the office of coroner, and in 1888 - when the Ripper murders began - a governmental act mandated that death investigation findings by coroners would no longer render any sort of financial benefit to the crown.
These important pieces of legislation are rarely if ever mentioned in connection with the Ripper crimes. Objective death investigation became a priority, and the possibility of material gain by the crown was removed. The change in law meant a change of mind-set that allowed and encouraged the coroner to concentrate on justice and not insidious pressure from the royals. The crown had nothing to gain by interfering with the inquests of Martha Tabran, Mary Ann Nichols, or the Ripper's other victims - even if the women had been upper-class subjects with influence and wealth. The coroner had nothing to gain but plenty to lose if the freewheeling press depicted him as an incompetent fool, a liar, or a greedy tyrant. Men such as Wynne Baxter supported themselves through respectable legal practices. They did not add much to their incomes by presiding over inquests, but put their livelihoods at risk if their integrity and skills were impugned.