Early Auckland coroner’s inquests

Authors note: This blog post contains medical details relating to the deaths of individuals. Some of the terminology used is out-dated and the subject could be sensitive for some readers. Some reports have been redacted to ensure respect is given to the victims.

One day while working the desk at Research Central, I mentioned to a colleague that I am fascinated by anything related to medical history (which might explain two of my previous blog posts about nursing and midwifery...). She quickly said “Oh, you’d like this book then!” and showed me ‘Touching on Deaths: A medical history of early Auckland based on the first 384 inquests’ by Laurie Gluckman. I was immediately hooked! This blog post will delve into the history of coronial practices in Auckland and will highlight a few of the more curious cases. 
The first chapters in the book examine the history of early Auckland Pākehā settlement, how the city developed, housing, roading and public health. The picture it paints is grim; filled with poor sanitation and disease, rampant alcoholism, rudimentary facilities, unruly behaviour and generally slow urban development all at the forefront of the history of Auckland that Gluckman recounts. This story is told to give some context as to the living conditions and the state of the city, which may help to explain some of the more obscure inquest reports and the circumstances surrounding some deaths. 

New Zealand Graphic. "The crusade against dirt and disease–insanitary and defective premises that the Auckland City Council has had condemned and done away with in the last few months", 19 July 1911, Auckland Libraries Heritage Collections NZG-19110719-25-1. 

The book also explores the early medical history of Auckland including hospitals, mental health institutions, mortuaries and, of course, coroners’ inquests. The Coroners Ordinance was passed on 15 October 1846 and stated that “Every person acting as a Coroner…shall have all such powers and privileges and be liable to all such duties and responsibilities as any Coroner in England”. This set a precedent for how coronial practices would operate in New Zealand from quite early on. Coroners were required to be medical men in order to make accurate deductions about cause of death and to be able to infer circumstances around the final moments of the deceased. This was crucial, particularly if there were to be judicial processes associated with the death. 

Auckland Weekly News. "Auckland City Coroner: Mr T Gresham", 10 May 1901, Auckland Libraries Heritage Collections, AWNS-19010510-10-3.

Much of the book is made up of summaries of the medical evidence given at 384 Coroners’ inquests into sudden, suspicious or unexplained deaths in Auckland between 1841 and 1864. These transcriptions come from four volumes of handwritten records which bear no Government seal or other official ownership. Fortunately, in January 2000 a reference archivist at Archives New Zealand was able to locate a box which contained many of the original Coroners’ Reports, which were sent monthly to the Law Office, and from which the four volumes were produced. Auckland Libraries holds these four volumes in our manuscript collection. They were donated by the Gluckman family and are available to view in the Special Collections reading room
Samantha Waru. Image of NZMS 1170 "Inquest Reports", 7 August 2020.
In 1867 the Medical Practitioners Act was passed, which meant that from April 1868 all practitioners had to be registered. Combined with work done by Coroner and Provincial Surgeon Dr Philson to refine medical classifications and recording, the way medical and coronial practices operated and were recorded had changed by 1868. This explains the specific time period that is covered in the volumes Gluckman found.

Henry Winkelmann. "Looking west from Gunsons in Customs Street West across...." showing the morgue centre left, 25 September 1912, Auckland Libraries Heritage Collections, 1-W1527

Let’s delve into some of the reports:

Coroner: Dr. Johnson, 27 July 1841 (page 117)
            Inquest held at the Police Office, Auckland 
Arthur Turtley sailed from Waiheke to Auckland on the 8th of July. His boat was found upturned the following day. 
Turtley’s body, discovered between two and three weeks later, was buried three days afterwards on a beach, above high-water mark, less than a week before the inquest. This was to prevent mutilation by dogs. After exhumation it was identified from clothing. There was no autopsy. 
Verdict: Death by suffocation and drowning as a result of accident. 

Coroner: Dr. Pollen, 28 May 1845 (page 132)
On Charlotte McCarthy 
T.S. Conway had known the deceased for about three and a half years. Her habits were very intemperate. He had been called to her and found her almost insensible and her extremities cold. He said that he prescribed for her and she died an hour and a half later. Conway said: “I am of opinion her death was caused by her habits of intemperance’.
Verdict: Her death occurred by Act of God in a natural way. 

Coroner: Dr. Johnson, 25 October 1847 (page 146)
Hannah Snow, wife of Lieut. Snow, was found dead in the burned remains of a house on the North Shore. 
John Clifford, Staff Assistant-Surgeon to troops stationed here was directed by the Coroner to examine the body. He said ‘I found the body... with a large wound...I am of the opinion the wound must have been given prior to the action of the fire on the body and that the wounds are of a depth and extent sufficient to have caused instantaneous death’. 
Verdict: Feloniously killed and slain by a person or persons unknown. 
The next report is that of Mary Snow, Hannah's daughter who was also killed and a part of the same house fire. There is a fantastic Radio New Zealand podcast called Black Sheep which has an episode about this infamous incident.

Coroner: Dr. Andrews, 7 July 1856 (page 211)
John Nolan fell dead while giving evidence in court. 
Dr. Mahon, one of the Bench of Magistrates, examined the deceased and declared him dead. There was neither medical evidence nor autopsy. 
Verdict: Visitation by God. 

Coroner: Dr. Philson, 8 December 1860 (page 270)
                             Inquest held at the Royal Hotel
William Rogan, aged about 20, was swimming at noon when, without warning, he sank. He as not a good swimmer. He was healthy, teetotal and subject to cramps. He had been warned of the dangers of swimming at noon. 
T.F. McGauran examined the deceased at the beach at about 2pm. He found no signs of life. He was told that the deceased had been twenty minutes under water, and half an hour out of it, when he arrived. It was evident to McGauran that death was the result of drowning. 
Verdict: Accidentally, casually and by misfortune, drowned.  

These six examples are just the tip of the iceberg when it comes to mysterious, unfortunate and sometimes horrific circumstances surrounding people’s deaths in early Auckland. The book contains details of 111 drownings, 91 alcohol related deaths, 54 attributed to ‘visitation by God’, as well as lunacy, sunstroke, gunshot wounds, poisonings, murder and other means. The picture painted by these reports tell us about the conditions at the time, they give insight into medical and judicial practices and they also offer a glimpse into the dangers of everyday life in the nineteenth century. 

Research Central has two copies of this book, as well as other holdings across the city for you to access. Other material that may be of interest is the "The New Zealand justice of the peace, resident magistrate, coroner and constable" and "A Handy book for the Coroners of New Zealand: Containing the Provisions of The Coroners Act 1867", both by Alexander J. Johnston.

Price Photo Company, Auckland Weekly News. "A much-needed institution: the new morgue and coroner's court recently erected in the hospital grounds, Auckland." 13 June 1912, Auckland Libraries Heritage Collections, AWNS-19120613-10-1.

Author: Samantha Waru