716 Journal of the Royal Society of Medicine Volume 86 December 1993
The Crowner's quest
Paul Knapman MRCS DMJ HM Coroner, Westminster Coroner's Court,
Horseferry Road, London SWiP 2ED, UK
Keywords: history; coroners
Introduction
The English are proud of their historical traditions.
Those who walk through the door at the Royal Society
of Medicine see portraits; we at the RSM are proud
of our historical heritage, and indeed members of the
History of Medicine Section of the RSM particularly
share that love of our heritage.
The Office of Coroner is one of the oldest known to
English Law. It is likely there was evidence of a
Coroner as early as the reign of King Alfred the Great
(871-910). Conventionally, the institution of the Office
is dated from the publication of the Articles of Eyre
1194 (an eyre was a periodical circuit of Justices).
So next year it will be 800 years since the formal-
ization of the Office of Coroner.
Chinese
The Chinese were there first! Professor Bernard
Knight of Cardiff has done some researches which
show that in 1975 in a tomb in Yunmeng in China,
bamboo slips were found dating from the period
475-221 BC. These were instructions to judges on
how to detect bruises, wounds and general post-
mortem changes.
In the Tang and Song Dynasties, which date from
618 AD there is clear evidence of the existence of
what we would call coroners in China. These were the
equivalent of judicial officers or magistrates and there
was in existence a rigid routine for investigating
deaths. A death in custody in China in that period
was taken seriously, paradoxically at a time judicial
torture was common. Autopsies, in the present sense,
by a doctor were not introduced in China until 1913!
The Magisterial Officials (or coroners) in the period
mentioned, well over 1000 years previously, would
stand within a regulation number of paces from the
corpse, whilst a lowly assistant (a combination of
porter, technician and undertaker) would carry out
a form of examination. So in the seventh century AD,
when a death occurred, this official (i.e. coroner) had
to respond within 4 h together with assistants and six
bowmen (i.e. guards). He had to interrogate witnesses,
arrest suspects, etc. Subsequently a post-mortem
report was made in triplicate and one was given to
the relatives.
A man called Sung T'Su wrote a practical manual
which still exists, dating from 1247. There are trans-
lations published in French up to 1910 and recently
in English in 1981. It is a book of 130 pages to guide
officials through a complicated set of rules. Much is
on hanging - to take careful note of the neck mark
and its relation to the larynx. Page after page of
instructions exist. Page 126 refers to a melancholic
face if it is a suicide (but that is not terribly reliable!).
Page 145 advises that the official should directly
inform a higher authority of a death of a person whilst Paper read
in custody. There were later editions of this book, with to Section of
a printed post-mortem form promulgated in 1304 with the History
the diagrammatic representation of a person in the of Medicine,
anatomical position, front and back, with instructions 2 December 1992
of what was to be filled in. (Professor Bernard Knight
has a copy of this post-mortem report form of 1304
in China.)
The Articles of Eyre and Magna Carta
By article 20 of the Articles of Eyre (1194), there was
provision for the election by every county of three
knights and one clerk as 'keepers of the pleas of the
Crown' or Custos Placitorum Coronas. The reference
to the Crown, Coronas, is the reason for the word
Coroner or Crowner.
The coroner had to be resident in the county or
(later) the borough for which he was elected. His other
qualification was his wealth. The fact that he was
required to be a knight with considerable financial
resources was probably seen as a form of insurance
against the possibility of misbehaviour - in the event
of which his lands or possessions could be confiscated.
The county coroner took his oath of office before the
sheriff and his tenure was for life and during good
behaviour. He would, however, lose his post auto-
matically if he was elected to the office of sheriff or
verderer. The office of coroner was unpaid. It was an
office of considerable power, and one suspects some of
the money collected might have stuck to his fingers
on the way to the King.
It is important to realize that throughout the mediaeval
period the coroner was concerned mainly with the
furtherance of the King's financial interest. Judicial
functions were of a secondary and, sometimes, only
incidental importance - and interest in medical causes
of death was virtually non-existent! During this
period, the whole of the judicial system was motivated
primarily by the prospect of securing revenue for the
Crown and, sometimes, for the judges. Criminals paid
heavily for their crimes, not only through loss of life
or privileges but also financially. Moreover, proven
criminals were not alone in suffering financial
burdens at the hands of the mediaeval judiciary. The
preservation of law and order was the responsibility
of the whole population. Consequently, the fact that
a crime had been committed, implied that the men
of the neighbourhood had failed in their duty. The
judicial authorities were therefore concerned, not only
with bringing criminals to justice, but also with
disciplining erring townships. Punishment meted out
to towns and neighbourhoods adjudged guilty of
failing in their duty took the form of heavy fines called
'amercements'. King Richard I (the Lionheart), of
course, required this money for his crusades.

The precise duties of the mediaeval coroner as
'Keeper of the King's Pleas' at the time when the
office was created, have never been authoritatively
established. The Articles of 1194 and the earliest
borough charters stated simply that coroners were to
'keep' (ie to record) pleas and other matters pertaining
to the Crown. Not until the second half of the
thirteenth century, when a respected writer called
Bracton wrote his treatise De Legibus Angliae, was
there any attempt at a comprehensive definition of
a coroner's duties. From Bracton and from the other
writers who followed him it is possible to identify
among a number of separate duties the holding of
inquests on dead bodies.
As the Keeper of the King's Pleas, the coroner had
no authority to act as a judge by trying pleas.
Nevertheless, it appears that the coroner did often try
criminal pleas, for in 1215 it was deemed necessary
to include a provision in Magna Carta to the effect
that 'no sheriff, constable, coroner or other of our
bailiffs, shall hold pleas of our Crown'. Despite Magna
Carta, coroners continued to act as judges in criminal
cases, and often conducted jury trials in ordinary civil
pleas, sometimes in association with a sheriff.
The mediaeval procedures
Most coroners' inquests were held on homicides and
deaths by misadventure but, from the earliest times,
a coroner was also expected to make inquiries when
death was sudden or unexpected, when a body was
found in the open and the cause of death was unknown,
and when a death occurred in prison. Anyone who
found the body of a person whose death was thought
to be sudden or unnatural was obliged to raise the
'hue and cry' and to notify the coroner. In many areas
the procedure was for the person who discovered the
body -'the first finder' to inform the 'four nearest
neighbours' who would notify the bailiff of the
hundred (ie area of a district council), whose duty it
then was to summon the coroner. Before holding an
inquest, the coroner had to view the body and he
therefore attended the scene of death immediately
he was summoned. Speed was important if he was
to have any chance of apprehending a suspect. It could
also help to ensure the preservation of the Crown's
financial rights, which might be lost if the body was
buried or removed. Great importance was attached
to the coroner's view of the body and it was the
responsibility of the neighbourhood or township in
which it was found to see that it was not interfered
with before his arrival. Failure to summon the coroner
or intentional removal or burial of a body might lead
to the amercement of the community at the next Eyre.
Inquests were always held with juries, which were
usually summoned by the bailiff of the hundred acting
on the instructions of the coroner. Originally the jury
consisted of representatives of four or more neigh-
bouring townships but in the last quarter of the
thirteenth century they were usually joined by 12
freemen representing the hundred. As they were
familiar with the area in which the body was found
and often with the circumstances surrounding death,
jurors also acted as witnesses at the coroner's
proceedings.
It was usual for the jurors to go to the scene and
to view the body with the coroner to see if there was
any evidence of wounding and to decide whether
death had occurred where the corpse was discovered
or elsewhere.
Journal of the Royal Society of Medicine Volume 86 December 1993 717
From 1194, for well over 100 years and probably 200
years, the coroner was a very important official in
mediaeval England. He was probably more feared
than even the sheriff of the county, one can reflect
from Robin Hood how feared was the sheriff. In those
days of rigid observance of laws there were various
'incidents' (so called) associated with death.
Murdrum
King Richard I came from the Norman line of kings
established in 1066. He was keen to keep the deaths
of Normans by murder or other unnatural means to
an absolute minimum. There was instituted the
'Murdrum fine' to be levied from the whole community
in the 'hundred' where the Norman had been killed.
The murdrum fine was only levied when a Norman
died. Anglo Saxons could die with relative impunity!
The fine had to be paid unless it could be shown the
slain person was not a Norman but an Anglo Saxon,
or Englishman. There was an elaborate procedure
called the 'Presentment of Englishry' (or in Wales,
Welshry) whereby witnesses would attest and demon-
strate the dead man was in fact not a Norman at all,
and so no murdrum fine had to be levied.
The imposition of this heavy fine in cases of
accidental death, even in sudden deaths of a kind
which we vaguely term 'natural' deaths, was bound
to be resented. Mounting discontent with this
extortionate exaction came to a head with the severe
winter of 1257-1258, which was accompanied by a
famine exceptional even by mediaeval standards.
Between 15-20 000 people are believed to have died
in London alone, and peasants flocked to the towns
in the hope of finding food. Matters were made worse
by speculators buying up the cargo of a relief corn fleet
sent from the Continent. Large numbers of peasants
died by the roadside with the result that the murdrum
was constantly inflicted as it was generally impossible
to prove Englishry. A writ issued to the sheriffs of the
eastern counties stated that 'many poor men die of
hunger in the fields, and for a long time their bodies
remain unburied: and no one dares to bury them
before the coroners have viewed them, nor can the
coroners cope with the cases and view them all'. It
concluded with the notice that in the case of such
deaths, the bodies could be viewed by the 'lawful men'
of the neighbouring townships, and buried, provided
no wound had been found and there was no suspicion
of felony. The deaths, however, still had to be enrolled
in the coroners' rolls. Simultaneously, the barons
complained that, because it was impossible to prove
Englishry in these cases, the districts were amerced
for murdrum by the justices. The following year in
1258 the Provisions of Westminster enacted the
murdrum would in future be imposed only in cases
of felonious killing, a concession which was re-
affirmed after the general pacification by the Statute
of Marlborough (1267).
The restriction of the 'lex murdrorum' to felonious
killing in the mid-thirteenth century detracted
considerably from the importance of the inquest on
sudden death. In mediaeval England it must be
remembered there was insistence on rigid adherence
to the proper procedure in the law. The extent to
which these rules were ingrained in the mind of the
mediaeval community is well illustrated by a case
which occurred 700 years ago at Bury St Edmund's
in 1293. There had been two sudden deaths, one of
a boy aged 12 who had been drowned, the other of a
718 Journal of the Royal Society of Medicine Volume 86 December 1993
man who had been crushed to death when a heavy
weight supporting a lamp which he was lighting in
the local church had fallen on him. The coroner could
not be found since he was away on holiday, as also
was the steward, who might have found a solution.
There was no method of getting a coroner to hold an
inquest, and the sheriff could not interfere without
special orders because the death had taken place in
a liberty. Eventually the relatives ofthe deceased had
to beg a remedy from the abbot, as they dared not bury
the bodies without a view by the coroner, and the
whole neighbourhood was beginning to suffer from
the stench.
Abjuration of the realm
In mediaeval England there were two types of
sanctuary for people on the run. Some abbeys and
minsters had sanctuary for a league surrounding the
building, but every consecrated monastery or church
could give sanctuary for 40 days. The majority who
sought sanctuary were robbers or murderers. Some
official (perhaps the bailiff) would organize the
guarding of such felons. The coroner was summoned
if the felon said he wished to abjure the realm.
Practice varied but often the whole township was
summoned to witness the abjuration and the spectacle
was popular. When the coroner arrived he gave the
felon the choice of either surrendering to the law or
abjuring the realm. The ceremony took place at the
gate or stile of the churchyard. The felon would
confess his guilt, and take the oath of abjuration,
swearing on the Gospels to leave the realm of England
and never return, except with the King's consent, and
to comply with the conditions of the coroner (to hasten
to the port, not leave the highway, not stay anywhere
for more than 1 night, at the port to seek passage
across the sea delaying only one tide if possible, and
if not, to walk into the sea daily as a token of his desire
to cross it, and if unsuccessful after 40 days to take
sanctuary again!). The abjuror was given a map by
the coroner indicating his route and originally had
to wear sackcloth, although later fairly normal clothes
were allowed (except head and feet uncovered). He had
to carry a wooden cross in his hand. Clothing and the
cross had to be provided by the township. The map
indicated the port to which he had to go, and practice
varied whether the coroner actually assigned the port
or allowed suggestions to be made. In one case the
abjuror asked for a port in Scotland, and the coroner
assigned him Dover! Apparently, regularly abjurors
from Yorkshire were sent to Dover!
Of course, many would-be abjurors changed their
minds and decided to wait the 40 days hoping to
escape. Many broke the conditions and merely left the
road when nobody was looking. Many were killed
along the road, presumably by the relatives of those
they had offended. If they broke the conditions they
were invariably hanged, if they were caught.
Approver
The coroner was also indispensable to the process
of turning approver, the mediaeval equivalent of
turning King's evidence. The convicted felon might
save his life by turning approver and challenging or
appealing a certain number of his confederates. First
of all he had to make a full confession, and for
this purpose he was assigned a coroner; if he was
successful in prosecuting the required number of
appeals - and this invariably meant challenging his
confederates to a battle - he would be allowed to abjure
the realm or would be sentenced to life imprisonment.
If he were unsuccessful, the original sentence of
hanging would be carried out. Turning approver was
a popular practice throughout the thirteenth century,
if only to put off the time of execution, and approvers'
duels were by no means uncommon. However, when it
came to the point, many approvers refused to confess,
or to prosecute their appeals. Of course, battle, or
ordeal (red hot irons) was a common way of settling
disputes according to law. Our adversarial system of
law comes from the idea of battle.
Deodand
Another valuable incident of sudden death was the
deodand. This was an object, animate or inanimate,
which was held to have the most proximate causal
connection with a violent death, whether accidental
or felonious in character. This object, which might be
a boat, a knife, a horse, a cart, or almost any other
object, was forfeit. The first official mention of the
deodand seems to have been in 1184, though it was
almost certainly in existence before this date. During
the mediaeval period it often happened that the crown
would renounce its right to the deodand in favour
of the deceased's dependants or some charitable
organization such as a religious institution. The
increasingly popular custom of granting to individuals
the right to receive certain 'incidents' of sudden death
including the deodand, led to the local lord of the
franchise at a later date claiming the deodand for
himself in many cases! (a development which led to
coroners' juries undervaluing the deodand). In some
cases the lord would procure himself to be appointed
foreman of the coroner's jury, thereby ensuring a
favourable valuation of the deodand!
With the introduction of mechanized transport in
the early nineteenth century, there took place a
remarkable revival in the economic importance of the
deodand, and ships, railway engines and carriages
were assessed as deodands at sums running into
thousands of pounds! Even at this late stage it was
possible to rationalize the continued existence of this
curious relic of the mediaeval period, and the
Registrar General in his annual report in 1841 stated:
The principle of the deodand too, is full of wisdom, as it
recognises the fact that accidental death may be indirectly
caused, and by inflicting fines on the owners of dangerous
animals, machinery, and other property, exercises a
substantial check upon responsible parties.
The overlong preservation of these obsolete incidents
of mediaeval law was capable of giving rise to
mischief. For example, there was a sale by auction
of the 'Hundred Court of Wirral' in 1820, together
with a number of ancient rights. The new owner
entered upon a scandalous career of exploitation,
invoking fines and amercements in the Hundred
Court. He went to town with treasure trove, wrecks,
the goods of felons, deodands and royal fish; this
culminated in the abolition of that Court by Act of
Parliament in 1856!
Treasure
The problem is always that the truth of which
official did what in mediaeval England, is far from
clear. It probably varied throughout the country
anyway. Opinions of various historians also differ

about coroners. There is a statute of 1276 Officium
Coronatoris which refers to the duty of the coroner
to hold inquests into wrecks, royal fish and treasure
trove. Royal fish were, of course, whale and sturgeon
and if they were found, presumably the King would
have standing arrangements for these to be given to
a local Baron.
It is still the law that treasure trove must be
reported to the coroner. The definition has three
ingredients. First, it must be made of gold or silver,
and manufactured. Secondly, it must have been
deliberately concealed by the owner with a view to
later recovery. Thirdly, the present heirs or successors
to any owner must be unknown. Thus, a coroner who
is informed of possible treasure trove within his area
must enquire into the matter. He will summon a jury
and hold an inquest. An inquisition will be drawn up
which will determine where the object was found,
what precisely constitutes the find, whether it was
intentionally hidden, whether the owner is known,
and who was the finder.
A usual example will be a small boy straying onto a
farmer's field with his metal detector in East Anglia.
He finds a hoard of gold coins. Eventually they will be
reported to the coroner. If it appears they date from
the Civil War, the jury will have to determine whether
a soldier, before a battle, buried them under the old
oak tree intending to return (and was killed in the
battle) or were they dropped or abandoned. If they
were hidden, they are treasure trove and belong to the
Crown (or the Duchy of Lancaster or Cornwall). The
Crown, however, has long been embarrassed by this
and will normally restore them to the finder. If they
were abandoned, they belong to the farmer on whose
land they were found. However, where they are of
considerable archaeological importance, the Crown
may insist they go, for example, to the British
Museum. The little boy will then get the value of the
objects as assessed by a special panel.
So much for the coroner in the mediaeval period when
he was at the height of his powers. During the
fourteenth and fifteenth centuries, a number of
changes were made in the country's legal system
which seriously affected the position of the coroner.
The general Eyre, which had never been popular, fell
gradually into disuse, and had virtually disappeared
by 1300: its end made an important contribution to
the decline in the status of the office of coroner. The
link between the coroner and the central law courts
which had been an important reason for creating the
office, was severed. The use of the general Eyre to
collect forfeitures to the King (held by the coroner)
had never been a profitable exercise, and once it
ceased it was never adequately replaced. Moreover,
the decline of the Eyre coincided with the rise to
prominence of two new local officials, the escheator
and the keeper of the peace, each of whom began to
assume some of the duties which had once been
performed by the coroner.
Escheator and Keeper of the Peace
The escheator was an official who made sure lands
reverted to the Crown (or the local Lord) whenever
possible. Whilst the escheator and the justices of the
peace had been busily taking over the coroner's duties
another serious blow was dealt to his status by the
abolition of the murdrum fine in 1340. With it was
lost a further incentive to hold inquests.
Journal of the Royal Society of Medicine Volume 86 December 1993 719
The Tudor and Stuart periods
The original role of the keeper of the peace was to
assist in the maintenance of order. However, his
peace-keeping duties were soon extended and he was
given power to arrest and make inquiries into felonies.
He then became known as the Justice of the Peace
and, as such, had power to 'hold' as well as 'keep' the
Crown pleas. He encroached more and more upon the
coroner's jurisdiction, sometimes acting with him, and
at other times in his place. By the end of the fifteenth
century the justices had reached a position where they
had control over coroners and jurisdiction over their
misdeeds.
By 1500 almost the sole remaining function per-
formed by the coroner was the holding of inquests into
violent death, but even these no longer had the same
importance as in the thirteenth century. With his
standing so diminished, it became increasingly
difficult to persuade the coroner to carry out his duties
conscientiously.
Despite the efforts of the Justices of the Peace, crime
continued to flourish in England and a great number
of murderers in particular must have gone unpunished.
In 1487 Parliament passed an Act which served both
as an inducement to the coroner to carry out his duties
diligently, and as a deterrent against his not doing
so. He was to receive a fee of 13s 4d for every inquest
held 'upon the view of the body slain', but if he failed
to do so, he would be fined the sum of 100s. The fee
was to be paid out of the chattels of the convicted
felon, or out of the amercement imposed on the
township, if the felon had been allowed to escape.
Seventeenth and eighteenth century
There was not much change for the next 200 years
or so. In the late seventeenth century and early
eighteenth century emigration from England occurred
to the New World. Just as emigrants took with them
the office of sheriff so too did they adopt the office of
coroner in a rudimentary form.
In England it was not until 1751 that action was
taken to improve the status of the office of coroner,
which had continued to exist in a moribund state. It
was acknowledged that the remuneration provided by
the Act of 1487 was inadequate reward for the general
tasks expected of a coroner and an Act of 1751
increased this by providing that he should receive a
fee of 20s and travelling expenses of 9d per mile - in
respect of all inquests 'duly held' (9d per mile is almost
equivalent to 5p). Instead of providing a basis for a
reformed coroner's service, the 1751 Act caused a
series of disputes between the coroners and the
judicial authorities which were to continue for more
than 100 years. The arguments arose because of
differences of opinion as to what constituted a 'duly
held' inquest.
The eighteenth century justices on the whole took
the view that the coroner was never intended to
inquire into sudden deaths unless there was manifest
evidence of violence, whilst the coroners contended
that their jurisdiction was to include all sudden and
unexplained deaths. The old problem, the Justices of
the Peace putting in their oar!
The places where inquests were held have varied
over the years. It would be common to hold the inquest
in a building known to everybody, and this would be
a public house or inn.
Later (1853) Charles Dickens in Bleak House
(Chapter 2. Our Dear Brother) writes:
720 Journal of the Royal Society of Medicine Volume 86 December 1993
The Sol's arms 1st floor where the Harmonic meetings take
place twice a week. . .
The Coroner frequents more public houses than any man
alive . . . The smell of sawdust, beer, tobacco smoke and
spirits is inseperable in his vocation from death in its most
awful shapes.
Our legislators still required the coroner to view
every body before inquest until 1980. Moreover, the
Lord Chancellor who has the power to make rules,
has made Statutory Instrument, the Coroners Rules
1984. Rule 11 (1) provides that no post-mortem shall
be made in a dwelling house or on licensed premises!
The nineteenth century
In the nineteenth century, two Acts of Parliament
passed in 1836 provide evidence of growing concern.
The first was the Birth and Deaths Registration Act
which provided for the registration of every death
occurring in England and Wales, and which placed
certain specific duties on coroners as well as on other
persons in some way connected with a death.
The second piece of legislation in 1836 was an Act
to provide for the Attendance and Remuneration of
Medical Witnesses at Coroner's Inquests. The Act
gave the coroner a specific power to order a medical
practitioner to attend an inquest and to perform an
autopsy if he were not satisfied that the cause of death
had been established. The inquest jury was empowered
to require the coroner to secure the attendance of
any medical practitioner if a majority of them were
dissatisfied with the evidence as to the cause of death
submitted by the original medical witness. The fees
of the medical witnesses were to be paid from the
funds collected for the relief of the poor. The effect
of the Registration Act was to cause many more cases
of sudden death to be reported to coroners, and
because of the other Act passed in that year, the
accuracy of the medical information supplied to
registrars was also improved.
In 1837 an Act was passed to provide that coroners
should be entitled by law to claim all reasonable
expenses for inquests, and not simply fees for medical
witnesses. The expenses were to be met from the
county rate or, in the towns, from the borough fund.
However, it was not until 1860, when the County
Coroners Act was passed to provide that county
coroners should be paid by salary rather than by fee,
that they achieved a degree of independence.
Almost as important as the passing of the 1860 Act
was the Report of a Parliamentary select committee
on coroners in the same year. It recommended that
a coroner's jurisdiction to hold the inquest should
embrace every case of violent or unnatural death,
sudden death where the cause was unknown and any
death where, although the death was apparently
natural, reasonable suspicion of criminality existed.
After 1860 the number of inquests rose sharply, but it
was not until 27 years later that the recommendations
of the select committee were implemented in the
Coroners Act of 1887.
Coroners Act 1887
The 1887 Act was a watershed in the development
of the office of coroner. In consolidating the law
relating to coroners, which remains the statutory
basis of the law today, the Act confirmed that the
emphasis was no longer to be on protecting the
financial interests of the Crown, but rather on
providing a service for the investigation of both the
cause of, and the circumstances surrounding, deaths
(for the eventual benefit of the community as a whole).
By the end of the century coroners were being
notified of about 60000 deaths a year -a figure
representing about 10% of all deaths in England and
Wales at that time. In almost a third of these cases,
however, no inquests were held. The coroner still
had no power to order an autopsy unless he held an
inquest.
The twentieth century
Finally in 1926 an Act was passed which meant it was
possible for a coroner to arrange for an autopsy in
order to dispense with holding an inquest. Today
about 80% of cases do not have an inquest even
though they are reported to a coroner. They are
natural deaths.
There has been a consolidating act namely Coroners
Act 1988. Whereas the Report of the Committee on
Death Certification and Coroners (the Broderick
Committee) of 1971, recommended that medical
practitioners should not be coroners, this has not been
enacted. A coroner may still be a 'medical practitioner
of not less than five years standing in his profession'.
Although it has been thought for some time the tide
was going out for purely medically qualified coroners,
there have been a few recent appointments.
Today the coroner must hold an inquest into all
those who die an unnatural death. It must be held
in public. The relatives must be allowed to ask
questions. In England no unusual or violent death is
ignored. In Nazi Germany before the war, bodies
were ignored by the authorities. In Argentina, no
inquiry was held into those who disappeared. In
England every case of unnatural death has to come
before the courts!
Thus we have a picture of an official who now, 800
years later, still takes an oath to serve his Monarch
in the office of Coroner (or should it be Crowner!).
(Accepted 23 March 1993)