Folk law | In suspicious circumstances

The coroner’s courts commenced in 1194 and are among the oldest courts still in existence. Richard I was on the throne when Article 20 of the Articles of the Eyre compelled each county of the realm to elect Keepers of the Pleas of the Crown know as ‘crowners’ from whence the name coroner is derived.

There is some obscure historical evidence to suggest that a type of coroner existed as early as the reign of Alfred the Great. But despite this great antiquity, the coroner’s position always has been that of Royal Servant rather than that of a judge and their power to proceed to trial and judgment was taken from them by the Magna Carta.

The primary function of the coroner’s office nowadays is to inquire into cases of violent, unnatural or suspicious death, together with cases of sudden death without apparent cause. Under section 5 of the Coroners and Justice Act 2009, the purpose of the investigation is to find out who has died, and how, when and where they came by their death, together with information needed by the Registrar of Deaths, so that the death can be registered. Although this seems a simple enough remit, the process of investigation of sudden and unnatural death has not been without controversy. Two coroners in particular attracted sensational and hostile publicity.

Death of a British legend

On Tuesday 21 May 1935 an inquest was held at Bovington Camp Hospital before the East Dorset coroner and jury. Its purpose was to ascertain the cause of death of a motorcyclist who had sustained fatal injuries when coming off his bike on the road between Bovington and Clouds Hill, Dorset. The victim was one of Britain’s greatest war heroes, Thomas Edward Lawrence, better known as Lawrence of Arabia. So how did this legendary man die?

The evidence at the inquest was conflicting. A large black car was said to be involved in the accident yet the coroner told the jury that the existence of this vehicle would have to be regarded as an irrelevance. The same eyewitness who spoke of the car said that Lawrence’s bike was travelling at 50 and 60 miles per hour when the accident happened, yet the mangled bike was recovered locked in second gear (yielding a speed of no more than 38 miles per hour). The coroner’s concluding words were: “he [Lawrence] had either had an accident on his motorbike or he had not,” leading to a verdict of death from injuries received accidentally. Strangely, Lawrence of Arabia was buried within two hours of the coroner’s verdict, leading to speculation of a coroner’s cover-up or that the death had been staged to enable T.E. Lawrence to spy on Nazi Germany in the coming storm.

The mystery of God’s banker

Gian Roberto Calvi was the president of Banco Ambrosiano, Italy’s largest private bank, whose clients included the Vatican (hence the name, God’s Banker). After the bank collapsed, Calvi was in London although nobody had seen or spoken to him during his stay. In the early hours of 18 June 1982, he was found hanging by the neck from scaffolding under Blackfriars Bridge. Bricks and stones were found in the pockets of Calvi’s well-cut Italian suit but there were no marks on the body to suggest violence, a struggle or lethal injection. The pathologist, Professor Keith Simpson, confirmed death by suicide. The inquest took place on 23 July 1982 and the coroner did not hear evidence from a single member of the banker’s family. At 10pm that evening, the jury pronounced suicide after being warned by the coroner against an open verdict. The Calvi family were outraged – they firmly believed God’s banker was murdered (Calvi telephoned his daughter the very evening he died to warn her that her life was in danger) and the verdict damaged Anglo-Italian relations.

Certainly, many factors did not add up – if Calvi wanted to take his own life why would he rummage around London to find bricks and stones, walk 4.5 miles across a strange city heavily laden, find Blackfriars Bridge and clamber up rusty scaffolding to hang himself? An overdose in his hotel room would have been simpler!

There were other discrepancies: there was no trace of rust from the scaffolding on the victim’s shoes and clothing; and the two watches found on the body had not been submitted for scientific testing – after examination they showed a different time of death. Lord Chief Justice Lane eventually overturned the dubious suicide verdict and ordered another inquest.

Dawn of a new death

Leaving aside the infamous cases above, serious concerns have been raised about the coroner system generally, compounded by a number of recent public inquiries: the crimes of Harold Shipman, the Marchioness disaster and the Bristol Royal Infirmary and Alder Hey hospital inquests.

Quite understandably, such shortcomings have led to a loss of confidence in the coroner’s ability to protect the public. A spokesperson for the campaign group INQUEST said: “each year tens of thousands of bereaved families grappling with the inquest process are forced to endure lengthy delays and an archaic, unaccountable system”.

The Coroner and Justice Bill, which led the 2009 statute, was a legislative response to those who had expressed concern about the coroner’s system. The post of Chief Coroner was created by the 2009 Act but has not yet been filled. This month, Judge Peter Thornton QC will become the first Chief Coroner of England and Wales. Mr Thornton is responsible for, among other things, improving standards, providing support for coroners, making changes to coronial training and monitoring investigations. Hopefully, these measures together with the appointment of more solicitors to the coroner’s office will restore public confidence in this oldest English court.