What Good is a Coroner? The Transformation of the Queensland Office of Coroner 1859 – 1959 Author Butterworth, Lee Karen Published 2012 Thesis Type Thesis (PhD Doctorate) School School of Humanities DOI https://doi.org/10.25904/1912/31 Copyright Statement The author owns the copyright in this thesis, unless stated otherwise. Downloaded from http://hdl.handle.net/10072/367859 Griffith Research Online https://research-repository.griffith.edu.au What good is a coroner? The transformation of the Queensland office of coroner 1859 – 1959 Lee Karen Butterworth BA (Hons I) A thesis submitted in fulfillment of the requirements of the degree of Doctor of Philosophy Griffith University School of Humanities Faculty of Humanities and Social Science April 2012 Statement of originality This thesis represents my own work. This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another author except where due reference is made in the thesis itself. ____________________________ Lee Karen Butterworth April 2012 Warning This thesis contains language and material that may be distressing for some readers. It includes descriptions of medical procedures and decomposing bodies. The case studies cover sensitive issues. Some readers may find the content of this work disturbing or offensive. No offence or disrespect is intended towards any persons living or deceased. 2 Abstract Coroners have always been associated with investigating death, but this ancient office has undergone considerable reform since its creation in the twelfth century. The role of the coroner of the twenty-first century involves investigating death, conducting autopsies, furnishing reports, issuing death certificates and if necessary, testifying in court hearings. However, the original function of the office of coroner was linked to raising revenue for the King in the form of large fines or “amercements”. By the fourteenth and fifteenth centuries the prestige and fiscal functions of the medieval coroner had diminished as a result of the increased power of justices. The gradual move away from justices’ control during the eighteenth century elevated the status of the coroner, whose role evolved into one that formed a more effective system for reporting and investigating cause of death. This in turn further legitimised the role of the office of coroner in the English legal system. It was this “modernised” institution that formed the foundation of coronial law and practice in Australia. Queensland adopted the English common law system from New South Wales when it became a separate colony in 1859. Consequently the ancient office of coroner was also transplanted to the new colony. As a self-governing colony, Queensland could enact new coronial legislation that better suited the conditions and circumstances of the expansive area under new settlement. This thesis looks at the first one hundred years of the office of coroner in Queensland, discussing the factors that led to its transformation from 1859 to 3 1959. The resulting history provides a platform to examine how the institution was formed and how it evolved into the system we recognise today. The data collected revealed a picture of a parsimonious government that marginalised the office of coroner in Queensland legislation. The government undervalued the institution of the inquest as a forum for public scrutiny and an instrument of justice and accountability. Research data were gathered from newspaper reports, coronial legislation, parliamentary debates, parliamentary papers and archival records. Queensland State Archive records were searched widely to create a comprehensive study of the Queensland coroner. A number of case studies, extracted from the inquest data and other primary sources, are cited throughout the thesis, and expose the functional strengths and inadequacies of the office of coroner. The research method created an extensive evidential base for the contemplation and analysis of how and why the function of the Queensland coroner changed over time. This detailed investigation of the evolution of the office of coroner in Queensland constitutes a substantive original contribution to the scholarship of Queensland history by creating an administrative and social history that fills a significant gap in the basic history 4 of the coroner. It also contributes to aspects of colonial legal and medical history, drawing on previously untapped sources. 5 Acknowledgements A number of people have made significant contributions to the writing of this thesis. I am thankful to my principal supervisor, Professor Mark Finnane, for his support, guidance and understanding. My associate supervisors, Associate Professor Regina Ganter and Dr Jonathan Richards, have been a great source of advice and friendship. I am especially grateful to Dr Richards for his generosity in sharing archival resources with me. Many thanks must go to my family. My husband Ralph, and daughters Haylee and Stephanie, who have always been supportive and encouraged me to continue when challenges arose. My parents Merv and Eileen Thorne, sister Kay O’Brien and brother-in- law Dr Patrick O’Brien, have provided sound advice and meaningful critiques. I also would like to thank Margaret Reid and Tilly Geary from Community and Personal Histories, Department of Communities. I value the working relationship we have developed and appreciate the enthusiasm you have shown for this project. Thank you to the staff of the Queensland State Archives, where I spent many long hours combing through thousands of records. A bonus linked to researching for this thesis topic was the pleasure of meeting Dr John Tonge, who provided an insight into his long career as a government pathologist. I would 6 like to acknowledge his valuable contribution of material. It has greatly enriched the content of this thesis. I extend my thanks to the following people who have all assisted me in some way during the writing of this thesis: Jillian Beard, Paula Campbell, Angela Darch, Elizabeth Davies, Karen Hands, Angela Hongxia Cai, Karen Laughton, Janice Mitchel, Tracey Michel- Innocend, Alex Naraniecki, Teone Reinthal, Dr Sally Rickson, Manjit Sanghera and Rebecca Ward. Thank you also to Sarah Casey for the company while writing late at night. I am indebted to Di Jeffries for editing the thesis. Your contribution in expertise, time and patience is very much appreciated. Finally, I dedicate this thesis to Karyn Capel and Meredith Scales, close friends who found time, despite their own suffering, to support me in undertaking this project. Sadly, Karyn and Meredith passed away before completion of this thesis. 7 Contents Abbreviations p. 12 Illustrations p. 13 Introduction p. 14 Literature Review p. 17 What the Literature Tells Us p. 40 Methodology and Sources p. 44 Chapter Outline p. 51 Chapter One: Investigating the Coroner p. 53 Introduction p. 53 Origins of the Coroner p. 55 The Nineteenth Century Coroner and the Medicalisation of the Inquest p. 62 Early Twentieth Century Reforms to Coronial Legislation p. 72 The New South Wales Office of Coroner p. 74 Conclusion p. 80 Chapter Two: The Inquests of Death Act of 1866 p. 83 Introduction p. 83 Administering the Fledgling Colony p. 84 The Coronial Inquest p. 97 Death Registration and the Medical Expert p. 106 The Office of Coroner: complications, inconsistency and lapses p. 110 Dr Henry Challinor: Coroner for Ipswich p. 122 The Inquests of Death Act of 1866 p. 140 8 Conclusion p. 147 Chapter Three: Six Decades Without Reform p. 150 Introduction p. 150 The Queensland Coroner after 1866 p. 152 Administering the Expanding Colony p. 153 The Development and Accuracy of Death Registration p. 163 Inquests on Fires p. 165 Matters of Economy p. 168 Coroners’ Fees p. 171 An Act to Save Money p. 173 Justice: not working to the letter of the law p. 178 John McCrae Inquiry p. 181 Overlooking Breaches of the Law p. 195 The Murder of Simon Zieman p. 195 The Maternal Death of Emmeline Trueman p. 199 Alice Mutlop: death of a domestic servant p. 204 Inquest Findings p. 207 Conclusion p. 211 Chapter Four: The Law Changes with a Young Girl’s Suicide p. 214 Introduction: the suicide of Dulcie Barclay p. 214 Why was the Barclay inquest adjourned and never reopened? P. 236 Coroners Act of 1930 p. 237 Conclusion p. 244 9 Chapter Five: Coroners Act 1958 p. 246 Introduction p. 246 Economic, Political and Social Upheavals p. 247 Outcomes of The Coroners Act of 1930 p. 254 The Disappearance of Marjorie Norval p. 261 The Coroners Act Amendment Act of 1943 p. 264 The Inquest p. 270 The Coroners Act Amendment Act of 1947 p. 273 The Coroners Act of 1958 p. 275 Coroners’ Riders or Recommendations p. 282 Coroners’ Findings p. 286 Conclusion p. 291 Chapter Six: Post-Mortems and Coroners’ Inquests p. 294 Introduction p. 294 The Rise of Forensic Medicine p. 295 Morgue Facilities and Post-Mortems in Queensland Rural Regions p. 297 Early Brisbane’s City Morgues p. 307 The Development of Forensic Medicine in Death Investigations in Queensland p. 310 The Alice Street Morgue p. 316 Extensions to the Morgue p. 321 The Institute of Forensic Pathology p. 323 A New Site for the Morgue and the 1956 Alterations p. 330 Morgue Site Protests and the Stigma of the Coroner’s Office p. 344 Conclusion p. 350 10 Chapter Seven: Conclusion p. 353 Appendices p. 360 Bibliography p. 372 11 Abbreviations ATSIOC Aboriginal and Torres Strait Islander Overview Committee CEQ The Committee of Elections and Qualifications CLO Crown Law Office IFP Institute of Forensic Pathology LRC Law Reform Commission NCIS National Coroners Information System NSW New South Wales QLD Queensland QPD Queensland Parliamentary Debates QPP Queensland Parliamentary Papers QSA Queensland State Archives QWEL Queensland Women’s Electoral League RCADC Royal Commission into Aboriginal Deaths in Custody UK United Kingdom UNSW University of New South Wales 12 List of Illustrations Figure 1: Geraldton Dead House 1886 p.