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‘ "Untimely ends": place, kin and culture in coronial inquests ’, Provenance: The Journal of Public Record Office Victoria, issue no. 18, 2020. ISSN 1832-2522. Copyright © Andrew J May, Helen Morgan, Nicole Davis, Sue Silberberg, Roland Wettenhall.

This is a peer reviewed article.

The authors are members of the collaborative Melbourne History Workshop in the School of Historical and Philosophical Studies at the University of Melbourne. Professor Andrew J May is an urban social historian whose publications include Melbourne street life (1998), Espresso! Melbourne coffee stories (2001) and The encyclopedia of Melbourne (2005) as director and lead editor. Helen Morgan is an information architect with multidisciplinary expertise in art history, professional writing, archival science and cultural informatics. Nicole Davis is completing a PhD thesis on the history of arcades in Australian cities and towns. Dr Sue Silberberg is a historian, curator and heritage consultant whose book A networked community: Jewish Melbourne in the nineteenth century was published in 2020 by Melbourne University Publishing. Dr Roland Wettenhall has recently completed a history of friendly societies in Victoria.

Lead author contact

Professor Andrew J May, School of Historical and Philosophical Studies, University of Melbourne

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This article explores the utility of using the rich holdings of coronial inquests in the collection of Public Record Office Victoria as fertile sources for exploring histories of place, kin and culture. It suggests ways in which the minutiae of everyday life contained in inquest deposition files provide a unique source enabling the historian to tell stories about ways of life as much as the circumstances of death. Coronial inquiries were established in the British legal tradition, with hotels playing an important early role in both the housing of dead bodies and the holding of inquests. The article further explores a range of examples under the themes of work, place, family and race to analyse the value of inquest files in understanding the experience of individual workers against the backdrop of occupational categories, to research fine-grained local histories, to disrupt racial stereotypes, and to understand family dynamics and extended relationships. These case studies throw light on a range of methodological and ethical issues pertinent to this genre of record, revealing inquest records as a complex body of important public documents with personal sensitivities, both for the historian and their subject.



At around 7 am on the morning of Monday 3 January 1898, 13-year-old Ralph Charles left his house at 9 Windsor Street, Footscray, on an excursion to Brooklyn. He met up with his 19-year-old brother Edwin, a civil servant of 58 Hamilton Street, Yarraville, and William Pearce, a coach painter of 8 Errol Street, and together the boys walked around 4 miles to Brooklyn Creek on a day’s rabbiting and fishing expedition. After setting their fishing lines in a quarry hole, John and William went off looking for rabbits and, on returning an hour later, found no sign of Ralph, though his lines were still in the water. Edwin noticed Ralph’s cap on the ground, and also that a branch with a nest of young birds had broken off a tree overhanging the waterhole and was now lying on the bank. After Edwin and William unsuccessfully dragged for the body with a piece of barbed wire, Edwin went off to telephone the police. On his return, the pair found the boy’s body at about 3.45 pm in 15 feet of water. His wrist looked broken and there was a wound on the heel of his foot. Edwin carried Ralph’s body 2 miles to Rumpf’s quarry at Spotswood, and thence to Footscray; the boys arrived at around 4.30 pm to break the news to Ralph’s father James, a quarryman. On 4 January 1898, William Gallant JP conducted a magisterial inquiry at Footscray Town Hall into the death of Ralph Frederick Charles and found that, though a good swimmer, he had accidentally drowned at Brooklyn while fishing—the assumption being that he had climbed the overhanging tree to see the bird’s nest and had fallen—and that there was no blame attributable to any other person.[1]

The tragic demise of one young life lies at the heart of this historical record, its emotional impact and reverberations for family and community barely captured in a legalistic and methodical evidence-based investigation. However, for the historian, evidence in a file such as this can tell us much more than the personal circumstances surrounding one unfortunate case. Information about age, residence, occupation (e.g., quarryman, coach painter and civil servant), locality (Rumpf’s quarry) or technology (the telephone) can add everyday personal and local detail to demographic or other historical generalities. Evidence of the activities of one particular child, moreover, can tell us about the experience of childhood in general in peri-suburban Melbourne at the end of the nineteenth century. In their quest for rabbits, fish and birds’ nests, the boys walked around 4 miles (over 6 kilometres) from Footscray to Brooklyn, extending our understanding from previous studies of children’s urban range as a historical measure of autonomy in the public realm.[2]

This article explores the richness of inquest records at Public Record Office Victoria (PROV) as unique and important sources for exploring histories of place, kin and culture, and for telling stories of life as well as death. After setting out the legal framework for the establishment of coronial inquiries, we will discuss a range of examples under the themes of work, place, family and race. In so doing, our task is to demonstrate the broad utility of using inquests as historical evidence: to understand the everyday experience of individual workers against the backdrop of occupational categories, to map communities against the patterns of their particular geographical localities, to disrupt racial stereotypes, and to understand family constitution and personal conditions and shed light on extended relationships. At the same time, our case studies illuminate a range of methodological issues pertinent to this particular genre of record: why it is important to consider how inquests were conducted (i.e., the question/answer format put to deponents) and how inquest records were created (transcription of testimony), what role gender might have played, what we may need to do to research deponents to fully understand their testimony, and how we can use newspaper accounts and other records to supplement information.

At a more fine-grained level, inquests also enable analysis of a range of variables that shape the cause, experience and aftermath of dying. ‘As mortals’, notes the ‘CSI: Dixie’ team at the University of Georgia, ‘we all die, but we do not die equally. Race, place, gender, profession, behaviour, and good and bad luck play large roles in determining how we go out of the world’.[3] Research into individual family histories reflects important light back on to the history of the family. Placing the history of our own families against the broader history of the family in colonial and postcolonial Australia makes genealogical approaches richer, and broader critical syntheses of demographic and social trends more complete. The detail of personal experiences in the everyday lives of Australian families—shaped by class, race and gender—transforms and is transformed by the broader cultural, economic and political context. It is in this sense that the history of families, as microcosms of the modern world, is essential to our universal historical understanding.[4] In a similar vein, the ‘trinity’ of family history, according to American historian Joseph Amato, comprises genealogy (‘the players on the program’), history (as everyday life at a micro-regional level) and storytelling (as anecdote, event, narration).[5]

Catie Gilchrist is correct in asserting in her recent study of Sydney’s coroner’s court cases that ‘Australian historians have not used coroners’ inquests in a detailed or systematic manner’ in major studies,[6] which is not to say that studies of crime, murder, suicide, infanticide, domestic violence, the court system in general, or women, children and the family, have not drawn on inquests as historical sources, as of course have biographical accounts. Regional history groups and genealogical societies have also consolidated information from inquests for family and local history research.[7] In the Victorian context, researchers have made good use of inquests to explain things about individuals and families: illness, relocation, connecting people to place, institutionalisation, road trauma, murder, infant life protection, public health and sanitation.[8] Madonna Grehan, for example, combines evidence from coronial inquests into maternal deaths with other historical sources to explore the nature of care provision in order to ‘illuminate the challenges of administering justice in what was a contested professional arena in the nineteenth century’.[9] Gilchrist herself draws substantially on newspaper reports, taking a thematic approach to Sydney deaths, which enables her to construct a lively and informative social history on all manner of topics, from accidents, alcohol and childbirth to diet, dress and workplace safety. The title of her book—Murder, misadventure & miserable ends—reflects a common and almost universal morbid fascination, observable in Australia, Britain and parts of Europe, with deliberate and accidental deaths, echoing the same sense of titillation that drew thousands of people to view unidentified or infamous corpses at nineteenth-century city morgues from Melbourne to Paris.[10] Simon Cooke’s benchmark social history of suicide in Victoria to 1921 analyses the inquest as a site for the construction of meanings of suicide during the nineteenth and early twentieth centuries, a period when the social isolation of a largely immigrant cohort created greater susceptibility to suicide and a little over 7,000 individuals took their own lives.[11] More recently, Carolyn Staines has employed a historical epidemiological approach to analyse coronial inquests into 1,162 drowning deaths in Victoria, identifying a ‘step wise pattern of reduction’ over the period 1861–2000. Early factors contributing to drowning deaths—such as unprotected hazards, alcohol intoxication, lack of supervision of children and the inability of people to swim—were increasingly mitigated, in part due to the role of coroner’s inquests in informing drowning prevention.[12]

Figure 1: Title page of the Coroners Act 1865.

Inquests were first held in Melbourne in 1840 and Dr William Byam Wilmot was appointed the first coroner.[13] Victoria inherited the role of the coroner through British common law. An 1865 statute (Figure 1) consolidating the law relating to the appointment and jurisdiction of coroners set out their principal task as being:

To enquire concerning the manner of the death of any person who is slain or drowned, or who dies suddenly or in prison or while detained in any lunatic asylum, and whose body shall be lying dead within the district … and to enquire into the cause and origin of any fire whereby any building ship or merchandise or any stack of corn pulse or hay or any growing crop … shall be destroyed or damaged.[14]

Coroners were empowered to impound a jury for this purpose (only after 1903 could inquests be held without a jury), and publicans were required to receive dead bodies into their premises (which, of course, usually had cool sub-floor cellars) and to host inquests if requested.[15] Jurors lists can place individuals in specific locations at particular times. For example, the 1848 inquiry conducted by Wilmot at the Richmond Hotel into the death of Samuel Grant, who, having come to Melbourne from Bong Bong on business was accidentally drowned when horse and rider fell off the punt crossing the Yarra River, recorded the names of 12 jurors, ‘good and lawful men of the district’, one of whom, William Oswin, was likely the publican of the hotel.[16] Together with individuals deposing evidence at an inquest, jurors (always male) were usually required to sign their name, which can often also give a clue as to whether or not they were literate (i.e., those who were not making their mark with a cross) (Figure 2).[17]

Figure 2: The mark of deponent William Baxter, giving evidence at the inquest into the death of fellow bootblack Michael Thomas, VPRS 24/P0, Unit 180, Item 1866/1117, Michael Thomas.

Inquest and other coronial records at PROV cover a range of materials relating to coronial investigations. Fire Inquest Records (VPRS 407) relate to the causes or origin of fires in the period 1858–1940, though their investigations do not extend to any resultant deaths.[18] Melbourne Admittance Books (VPRS 7662, 1931–1959) contain information concerning bodies removed to the city mortuary, including about deaths that did not result in an inquest. Post-mortem investigation records, also known as body cards (VPRS 10010, 1959–1985) relate to coronial investigations at Melbourne and include records of investigations that did not proceed to an inquest. Inquests into deaths (deposition files 1840–1985) is a substantive open-access series covering 1840–1985 (VPRS 24) that is among the more popularly accessed records in the Victorian archives. If someone was charged over a death, the inquest file will be found in VPRS 30 (criminal trial briefs) rather than remaining in VPRS 24. Inquests from 1840 to 1937 are being progressively digitised and are accessible online up to the mid-1920s.[19] While the content of inquest files can vary over time, records commonly include the coroner’s verdict, a list of jurors, depositions of evidence given by any witnesses, a police report, and (from the 1950s) other exhibits or photographs.

Work and occupation

Inquests provide many important insights into working lives, especially at a time when occupational health and safety measures were nascent or non-existent. A range of studies have drawn on inquests for details on health and social and economic conditions of the rural working class,[20] or labour conditions, occupational risks and working technologies in particular industries.[21] Recent research to identify officers, field services workers or contractors of the Victorian Department of Environment, Land, Water and Planning and its precursor organisations who suffered a workplace fatality determined that inquest records provided the most useful and accurate sources on workplace fatalities. However sketchy employment information may be, information in inquests can be matched with other primary and secondary sources to determine verifiable cases. A search of the online inquest index[22] using pertinent keywords related to forestry-related deaths (e.g., forest, fire, bushfire, flood, timber, tree, employee, contractor, burn, explosion, blaze) narrowed the research to 28 hard copy inquests and several hundred digitised inquest files, which could then be analysed for relevant content. Sampling by event date—for example, the Red Tuesday fires of 1 February 1898—also returned relevant files. In most cases, while the occupation of deceased individuals was usefully described (farmer, mill worker, labourer, engine driver, ropeman, overseer, logging contractor), their employer was rarely specifically described. When it was, employers in the case of forestry-related deaths tended to be timber milling companies (e.g., Sanderson’s Sawmill, Edmond Robinson, Parbury’s Sawmill, John Hay & Co.’s Sawmill, Angliss Sawmill, Broomfield and Goeman).[23]

The search function enables interrogation of the archive via occupational status, which can then enable cohort analysis of particular occupational groups. Between 1854 and 1869, for example, there were nine inquests into the deaths of men who worked in the streets of Melbourne as shoeblacks or bootblacks, enough for some particular patterns to emerge (Table 1).

Table 1: Inquests of Melbourne bootblacks 1854–1869 (PROV VPRS 24/P0)


William Swain


‘cripple, and obtained his living by begging’

Chronic inflammation of the membranes of the brain


John James Sutherland


Unmarried, drunk, no doctor to attend him

Fracture of the skull


Thomas Copeland


‘a shoe black in the streets’

Disease of the heart liver and kidneys produced by habits of intemperance


Joseph de Gusperri


‘Swiss … without relatives in the colony he was a gold digger … a drunkard…he had no settled home’

Tubercular pneumonia and pericarditis


John Exford


‘single without relatives in the colony … a drunkard’

Disease of the heart


William Stockdale


‘no friends in the colony’

Serous apoplexy


Michael Thomas


‘a pensioner he was single … drank very much ’

Disease of the liver and spleen


William Lancaster


‘had a wife and family in England’

Disease of the brain, lungs liver and kidneys


Edward Morcam


‘not married … a great drunkard’

Sanguineous apoplexy


Previous research has identified 188 individual men who had permission from the City of Melbourne to shine shoes in the streets between 1868 and 1923.[33] The shoeblack of the 1850s was most likely to be a juvenile, as depicted in Henry Heath Glover’s 1857 lithograph, but by the time ST Gill caricatured the same occupation in 1869 (‘Ease without opulence’), he was clearly a dishevelled older man (Figure 3).[34]

Figure 3: ST Gill, ‘Ease without opulence’, 186-, National Library of Australia, available at <>, accessed 3 November 2020.

Analysis of the evidence from witness depositions and medical reports in the inquest files provides a better picture of this cohort of the casual urban labour force. A precarious occupational category at the best of times, scraping a meagre living in a lowly and often despised street occupation, they reveal themselves to be the castoffs of a goldrush generation: mostly single men, with no relatives or friends in the colony, heavy drinkers and suffering the health effects of its addiction. The ages for this small sample of nine men as recorded by witnesses are clearly approximations, as six of them were rounded to the decade (three aged 40, two 50 and one 60). In a friendless world of immigrants and strangers, coupled with a lack of official documentation (civil registration of births only dated from the 1850s), this is an object lesson in the inaccuracies of ‘official’ documentation.[35] Further, to a current-day reader, their ages may seem to range from young men to middle age; however, given that the life expectancy of a man born between 1881 and 1890 was 47 (compared to 80.5 for a boy born in 2015–2017), the majority of these men were definitively elderly by the measure of the day.[36] Finally, crosschecking the names of three of the bootblacks reveals inconsistencies in the data that are the likely result of errors in transliteration and rendering spoken into written word, and/or the difficulties of reading handwriting: with Victorian birth, death and marriage indexes (where Joseph de Gusperri[37] is listed as Joseph Gasperre[38]); with newspaper references (where Edward Morcam is recorded variously as Edward Morecum [39] and Edward Morceau[40]); and with the online inquest index itself, which incorrectly records Michael Thomas as Thomas Michael.[41]

Place and local history

As inevitably as local residents have lived and died in localities across Victoria, they have left traces of their attachment to place in the archive. Inquests have been a critical source in the armoury of the local historian, often one of the few records that can pin individuals to place, particularly in the early years of the colony. Dawn Peel’s study of Colac in 1857 gleaned precious minutiae from inquest depositions[42] and Joan Hunt’s history of Piggoreet identified the value of coroner’s inquests as being ‘their ability to reveal something of the daily lives of families’.[43] For the purposes of this article, we take one locale in Footscray to exemplify the rewards of exploring inquests as primary sources for local history, based on a range of inquests examined as part of a heritage study of sites along the Maribyrnong River.[44] The study area was historically significant as the location of the first direct crossing of the Saltwater River at a punt established on the initiative of William Lonsdale in 1839 on the road to Williamstown and Geelong. The locality of the punt as a transport node, the subsequent inns that were established to service the needs of travellers and the natural advantages of the river combined to make the nascent settlement an important interchange from the very earliest years of European settlement in the district. With sparse contemporary descriptions of Footscray’s social life in the 1840s and 1850s, inquests are a profitable source of information. In the immediacy of witness statements, we not only become privy to personal trauma and tragedy, but also are led incidentally into the thoughts, motives and reactions of a contemporary society that left few other written records of daily life. Maps, land records and other statistics can draw lines on the ground, but inquests reveal a world of affect and action, of aspiration as well as the quotidian world of children, women, leisure, clothes, work, social rituals, food, family and education. With its riverside location, the people on the Maribyrnong were also susceptible to the dangers of the river. An abstract of inquests held before coroners or inquiries by justices for the second six months of 1853 reveals that of the 172 accidental deaths in Victoria, 69 (or 40 per cent) were from drowning.[45]

In April 1847, an inquest into the death of Thomas Gaskell, found drowned in the Saltwater River, conclusively links Henry Kellett with the Bush Inn.[46] Inquests were held at the Stanley Arms Hotel (1857, 1859, 1862 and 1863), the Punt Hotel (1861 and 1862) and the Bridge Hotel (1864). These assist in building a collective picture of the rhythms of life in a riverine community, helping to reconstruct patterns of travel and communication and reveal the shifting variety of maritime activities over time: for example, with references to the captain of the steamer Hercules, a lighterman finding a dead body,[47] a drowned man who had been in charge of a Hulk moored opposite the Punt Hotel[48] and a young lad who fell out of a boat when his oar slipped out of the sculling notch.[49] The occupations of both witnesses and deceased reveal a variety of jobs in the 1850s and 1860s: for example, labourer and carpenter in the employ of Messrs Philpotts melting down works (1850), butcher and cook at Raleigh’s (1851), fisherman and farmer (1852), shipbuilder and fellmonger (1854), quarryman at the Junction (1857), drayman working on the railway (1857), master mariner (1862), and soap and candle maker working for Mr Hayes on the Melbourne side of the river (1862). Work was not always easy to come by:

Abraham Sharp, a labourer, had been working some time on the Govt Line as a Plate layer … He had been ill about three weeks & was low spirited from that & his not being able to get work. He went to Wms Town to look for work & on his return, he told me that he would not scruple to put an end to himself. Has no friends in the country.[50]

A number of deaths were indeed attributed to suicide by drowning.[51] Inquest records do not always make pleasant reading, and the residents on the riverside, the jury, the coroner and the local constable alike often faced the disagreeable tasks of dragging the river for bodies (some of which had been in the water for weeks and were so decomposed as to be unrecognisable), shifting them to a hotel for the inquest and/or making a close examination of the deceased. Yet, the records also provide a unique glimpse of personal tragedy, social attitudes, sentiment and the sometimes fatal end to lives in a new land.[52]

Births are recorded from the Saltwater River locality from the 1840s, and early inquests often record infant mortalities. The most common cause of death was drowning, and witness statements reveal the everyday activities of children as well as the parental challenges of surveillance.[53] In addition to their central role in child rearing, women made a significant contribution to the household economy, engaging in many tasks such as milking cows, preparing food and chopping wood. Tragic accidents reveal the demands on women as well as their strength and resourcefulness.[54] Other inquests suggest the common fate of young children who were accidentally overlain or smothered in bed.[55] A jury in 1856 concluded in another case that it was impossible to determine whether a dead child had been stillborn or murdered: ‘but from the fact of a rope wound round the body, the jury are inclined to think that some person or persons unknown may have thrown the child into the River to avoid a discovery of shame’.[56]

Leisure time was often taken up with attending the races at present-day Flemington, bathing or going up the river for a day’s shooting, a pastime often also indulged in by visitors from Melbourne. Fishing too was a popular activity as well as an economic necessity. When bodies were plucked from the river, police reports often contained a description of what the deceased was wearing as a clue to identification, which, for the researcher, serves as evidence too of typical fashions of the day—from cabbage tree hats and high-low, blucher and wellington boots, to pilot-cloth and moleskin trousers, monkey jackets, Crimean and Gurney shirts, Bedford-cord trousers and worsted socks.[57] While death by accident was often linked to the loose behaviour that came with drunkenness, both on land as well as on the river, not all the inhabitants were partial to strong drink. The father of a nine-year-old boy who drowned while out fishing with a Mr Williams blamed the man for not looking after his son but also himself for allowing the child to go fishing on the Sabbath.[58]


Studies of Bendigo and Vaughan Springs have been able to determine the living and working experiences of Chinese miners in regard to health, nutrition, accidents and general working conditions through insights gained from local inquests, enabling Valerie Lovejoy to argue that ‘Chinese miners led full lives on the goldfields, supported in sickness and in health by strong networks of relatives and countrymen with whom they enjoyed their leisure time’. [59] Our next two examples are inquests of a Chinese baby and mother who died in 1865 and 1870, respectively. These were the daughter and wife of Chinese storekeeper, Fong Fat, owner of a fancy goods shop on Swanson Street, Melbourne, and, later, the Eastern Arcade on Bourke Street, who arrived in Victoria in 1857.[60]

Ah Chow, the four-month-old child of Fong Fat and his wife, Quinti, was born in Victoria and died in July 1865 of inflammation of the lungs. The inquest reveals a little of their lives, with testimonies not only from the father (who discusses the child’s mother) but also non-Chinese neighbours and associates, including neighbour Bridget Gallagher, who did some housekeeping for the family.[61]

Five years later, Canton-born Quinti (who seems to have arrived not long before the birth of her daughter) died at their Swanston Street home of ‘a serious apoplexy from disease of the brain’, aged 24. According to newspaper reports, she had been ‘out of her mind’ for five and a half years.[62] Quinti’s inquest is mislabelled in the PROV index as being the inquest of a male named Fong Fah.[63] The inquest contains depositions from Fong Fat and the family’s housekeeper/shop assistant, Catherine Downey, a widow, whom Fong Fat married the next year. The inquest of Quinti was claimed in the press to be ‘probably the first inquest on a Chinese woman in Australia’, although that of her daughter was held five years earlier. [64]

Newspaper reports on the inquest, found when researching Fong Fat himself, led to the inquests at PROV, then the birth certificate for Ah Chow and her death certificate, as well as those of Quinti, Fong Fat’s second wife, Catherine Downey, and the man himself.[65] Together with these other records, the inquests provide useful insight into the lives of Fong Fat, Quinti and their baby daughter. While these give quite small snippets of the Chinese–Australian experience, when read alongside other sources, they shine further light on these histories, which often portray Chinese goldfield’s sojourners as having no family in Australia, or as taking non-Chinese women as wives despite having wives and family in China.[66]

This is an interesting case of a Chinese storekeeper catering to settler colonial tastes for Chinese wares (he sold imported Chinese fancy goods such as ivory boxes and fans), as well as tea and perhaps opium, in the centre of Melbourne. His shops were just outside the supposed Chinese enclave, although close to it, on Swanston Street and in the more elite setting of the Eastern Arcade on Bourke. They are of further interest as they reveal a little about Chinese women and families in the period. The Victorian census indicates that there were only eight Chinese women in the colony in 1861 and 34 in 1871. The presence of these females in the archival record disrupts the idea that Chinese women were not present in Australia and de- anonymises two of them.[67] Tantalisingly suggestive of what life was like for Chinese women in Australia, they put a human slant on the often racialised and sensationalised newspaper reports about the Chinese community in colonial Australia.

Kith and kin

In the early morning of 16 December 1877, a large storm blew over Melbourne and a 16-foot, heavily decorated chimney fell from a house on the corner of Jackson and Acland streets, St Kilda, killing both Esther Marks (nee Woolf, aged 39) and Julian Jacobs (aged nine). Esther and her husband Nelson Samuel Marks were living in a single storey rented house. On the weekend of 15–16 December, Nelson was in Gippsland on business, while his wife was at home with their adopted nephew Julian Emanuel Jacobs, his cousin Miss Levinson and another nephew Henry Robert Woolf. This complex family group raises a number of questions. Henry Robert Woolf’s father had died in New Zealand when Henry was a baby and he had been apprenticed to his uncle in business as a manufacturing chemist. But this does not explain the presence of the other children. Julian’s parents lived nearby in St Kilda, while the Levinsons had recently moved from Ballarat to Victoria Parade. While both the Levinsons and Jacobs each had 12 children, it is unclear why they were not in the care of their relatively well-off parents, and, therefore, why they were living with the childless Marks family. Nor is it clear why Julian Jacobs was sharing a room with his aunt.[68] This vignette, gleaned from inquest depositions and newspaper reports, serves as a starting point for exploring some of the benefits of using inquests as sources for family history. While it raises as many questions as it perhaps answers, it demonstrates the kind of detail available in some inquest files that can assist in unravelling the at times complex web of family structure and extended familial interrelationships.


As a range of our examples have shown, for the family and local historian, Victorian inquest files, like many archives—created as public records but not necessarily intentionally for general public consumption—bequeath us an extraordinarily rich body of data that, when alert to some of the methodological pitfalls, can be used to tell individual stories as well as for larger analytical and aggregate purposes.

The PROV website contains an apposite warning for researchers planning to explore Victorian inquest records: ‘The photographs in these records can be upsetting for some researchers. Spaces are available in our reading room for people who wish to view inquest records in private’. Just as the material they contain can be unsettling in the present, so too it was originally created and experienced with a personal force and emotional valency that demands sensitivity from the researcher to the realities of the past. The archive of the coroner’s inquest, in other words, sits within competing imperatives of open and transparent justice on the one hand, and personal sensitivity and private trauma on the other.[69]

Our examples have revealed a moral purpose and ethical responsibility in this endeavour, both in seeking the voice of victims (whether of circumstance or of larger historical forces) and in ensuring that we remain attuned to the agency of the individual and the actualities of their existence (even in the face of the bureaucratic abstraction of official records). Amato succinctly voices this imperative: ‘If I were to put an individual and human face on the family’, he asserts, ‘I could not treat the family as mere molecules in the flow of a great river, nor portable mannequins for my research generalisations’.[70] Conversely, as Holly Crossen-White cautions, the availability of online digital archives shines a light onto a level of detail about our forebears that they may not wish to have illuminated.[71] Greg Dening puts it slightly differently: ‘The dead’, he figures, ‘need history for the voice it gives them’.[72] The historian’s opportunity—indeed, we might say, duty—is, thus, to be responsible to the people of our past.



[1] PROV, VPRS 24/P0, Unit 682, Item 1898/32. The press reported the incident with just a few additional details: ‘Drowned while fishing’, Age, 4 January 1898, p. 5; ‘Drowned through bird’s nesting’, Age, 5 January 1898, p. 7.

[2] Simon Sleight records 3.15 kilometres as the maximum urban range in a cohort of 56 young people aged three to 16, calculated from cases recorded in the Melbourne City Council Town Clerk’s files, 1892–1900. Simon Sleight, Young people and the shaping of public space in Melbourne, 1870–1914, Ashgate, Farnham, 2013, pp. 67–75 and Table A.1.

[3] ‘CSI: Dixie. The view from the American south’s county coroners’ offices, 1800–1900’, available at <>, accessed 4 May 2020.

[4] Patricia Grimshaw, Chris McConville and Ellen McEwan, Families in colonial Australia, George Allen & Unwin, Sydney, 1985.

[5] Joseph A. Amato, Jacob’s Well: A case for rethinking family history, Minnesota Historical Society Press, St Paul, 2008, pp. 10–14.

[6] Catie Gilchrist, Murder, misadventure & miserable ends: tales from a colonial coroner’s court, Harper Collins Publishers, Sydney, 2019, p. xiii.

[7] For example, a mining accidents index compiled by the Ballarat Genealogy Society, and a list of local inquests compiled by both the Castlemaine & District and the Avoca & District historical societies, were used to build up a database of local hotels, publicans, doctors and midwives.

[8] Rick Clapton, ‘Keeping order: motor-car regulation and the defeat of Victoria’s 1905 motor-car bill’, Provenance, no. 3, 2004, pp. 12–24; Fred Cahir and Ian D. Clark, ‘The case of Peter Mungett: born out of the allegiance of the Queen, belonging to a sovereign and independent tribe of Ballan’, Provenance, no. 8, 2009, 29–45; Helen D. Harris, ‘Victoria police involvement in the Infant Life Protection Act 1893–1908’, Provenance, no. 9, 2010, pp. 73–79; Janet Marles, ‘Everything changes: piecing together evidence for a story of loss and absence’, Provenance, no. 9, 2010, pp. 80–88; Lee Hooper, ‘Preparation for death: the story of Francis O’Brien, Mildura High School headmaster and family annihilator’, Provenance, no. 13, 2014, pp. 76–85; Jacquie Browne, ‘Who says “you can’t change history”?’, Provenance, no. 14, 2015, pp. 131–145; Barbara Minchinton and Sarah Hayes, ‘Dating Melbourne’s cesspits: digging through the archives’, Provenance, no. 16, 2018, pp. 61–67; Cate O’Neill, ‘“She had always been a difficult case … ”: Jill’s short, tragic life in Victoria’s institutions, 1952–1955’, Provenance, no. 14, 2015, pp. 40–55; Keith Macrae Bowden, Doctors and diggers on the Mount Alexander goldfields, KM Bowden, Maryborough, 1974.

[9] Madonna Grehan, ‘“A most difficult and protracted labour case”: midwives, medical men, and coronial investigations into maternal deaths in nineteenth-century Victoria’, Provenance, no. 8, 2009, pp. 106–114.

[10] Andrew Brown-May and Simon Cooke, ‘Death, decency and the dead-house: the city morgue in colonial Melbourne’, Provenance, no. 3, 2004, 25–36.

[11] Simon J. Cooke, ‘Secret sorrows: a social history of suicide in Victoria, 1841–1921’, PhD thesis, University of Melbourne, 1998.

[12] Carolyn Staines, ‘History of drowning deaths in a developing community: the Victorian experience’, PhD thesis, Monash University, 2013.

[13] Simon Cooke, ‘Coroners’, in Andrew Brown-May and Shurlee Swain (eds), The encyclopedia of Melbourne, Cambridge University Press, Melbourne, 2005, pp. 173–174.

[14] An Act to Consolidate the Law relating to Coroners, 28 Vict. No. 253, 9 May 1865, available at <>, accessed 3 November 2020.

[15] Simon Cooke, ‘Inquests’, in Andrew Brown-May and Shurlee Swain (eds), The encyclopedia of Melbourne, Cambridge University Press, Melbourne, 2005, p. 366.

[16] ‘Body found’, Argus, 14 November 1848, p. 3; ‘Inquest on the body of Mr. Grant’, Melbourne Daily News and Port Phillip Patriot, 15 November 1848, p. 2; ‘Melancholy accident’, Geelong Advertiser, 14 November 1848, p. 2. William Oswin is recorded as the licensee of the Punt Inn, Richmond, in 1853. See Robert K Cole, Index of Victorian hotels: manuscript 1841–1949, State Library of Victoria.

[17] According to Cooke, Secret sorrows, p. 439: ‘The assumption that coroners did not deliberately select literate witnesses is supported by evidence suggesting that the proportion of witnesses able to sign their names was similar to the proportion of people able to do so in the Victorian population’.

[18] Records of investigations leading to criminal charges of arson are contained in criminal trial briefs. Fire inquests 1940–1959 can be found in inquest records, and for records from 1959–1985, see autopsy and investigation records.

[19] Inquests post-1986 are closed to the public and access is through the coroners court.

[20] Lisa Hay, ‘Finding Thomas Brookhouse: locating the nineteenth-century Western District rural working class through public records’, Provenance, no. 15, 2016–17, 9–17.

[21] Susan Walter, ‘Quarry and stone research methods: looking for holes in history’, Provenance 15, 2016–17, 35–46.

[22] Public Record Office Victoria, ‘Inquests into deaths’, available at <>, accessed 4 May 2020.

[23] Andrew May, Roland Wettenhall, Helen Morgan, Henry Reese and Gretel Evans, ‘Final report for DELWP on historic workplace (occupational) fatalities’, Melbourne History Workshop, School of Historical & Philosophical Studies, University of Melbourne, October 2019.

[24] VPRS 24/P0, Unit 21, Item 1854/493, William Swain.

[25] VPRS 24/P0, Unit 71, Item 1859/955, John James Sutherland.

[26] VPRS 24/P0, Unit 96, Item 1861/340, Thomas Copeland.

[27] VPRS 24/P0, Unit 132, Item 1863/1032, Joseph de Gusperri.

[28] VPRS 24/P0, Unit 146, Item 1864/855, John Exford.

[29] VPRS 24/P0, Unit 156, Item 1865/347, William Stockdale.

[30] VPRS 24/P0, Unit 180, Item 1866/1117, Michael Thomas (incorrectly indexed as Thomas Michael).

[31] VPRS 24/P0, Unit 176, Item 1866/648, William Lancaster.

[32] VPRS 24/P0, Unit 229, Item 1869/921, Edward Morcam.

[33] Andrew J. May, Melbourne street life, Australian Scholarly Publishing, North Melbourne, 2017, p. 158.

[34] Henry Heath Glover, ‘11 o’clock’, in ‘12 hours road scraping in Melbourne: scraped from the streets’, c. 1857, State Library of Victoria, available at <>, accessed 3 November 2020; ST Gill, ‘Ease without opulence’, 186-, National Library of Australia, available at <>, accessed 3 November 2020.

[35] Cooke, Secret sorrows, p. 441.

[36] Australian Institute of Health and Welfare, ‘Deaths in Australia’, web report, 17 July 2019, available at <>, accessed 4 May 2020.

[37] VPRS 24/P0, Unit 132, Item 1863/1032.

[38] Births Deaths and Marriages Victoria, ‘Research and family history’, available at <>, accessed 3 November 2020. See record 8751/1863.

[39] ‘Inquests’, Argus, 13 November 1869, p. 1.

[40] ‘Sanguinous apoplexy’, Herald, 11 November 1869, p. 3.

[41] VPRS 24/P0, Unit 180, Item 1866/1117. Births Deaths and Marriages Victoria gives his name as Richard Thomas. See record 11421/1866.

[42] Dawn Peel, ‘Colac 1857: snapshot of a colonial settlement’, Provenance, no. 7, 2008, pp. 73–81.

[43] Joan Hunt, ‘Piggoreet: a township built on gold’, Provenance, no. 12, 2013, 18–25.

[44] Alan Mayne, Andrew May and John Lack, Heritage survey. Quay West development site. Part 1: main report, 1989.

[45] Victoria. Inquests. Laid upon the council table by the attorney general, by command of his excellency the governor, and ordered by the council to be printed, Government Printer, Melbourne, 1854.

[46] VPRS 24/P0, Unit 4, Item 1847/26, Thomas Baitson Gaskell.

[47] VPRS 24/P0, Unit 68, Item 1859/599, unknown male.

[48] VPRS 24/P0, Unit 29, Item 1855/729, William Holloway.

[49] VPRS 24/P0, Unit 27, Item 1855/476, John Wade.

[50] VPRS 24/P0, Unit 70, Item 1859/862, Abraham Sharp.

[51] VPRS 24/P0, Unit 6, Item 1849/39, Edwin Elwin.

[52] VPRS 24/P0, Unit 48, Item 1857/71, Katherine Kleinhen.

[53] VPRS 24/P0, Unit 73, Item 1859/1096, James Young.

[54] VPRS 24/P0, Unit 5, Item 1848/29, Thomas Gorman.

[55] VPRS 24/P0, Unit 109, Item 1862/161, JA Landorf.

[56] VPRS 24/P0, Unit 38, Item 1856/99, unknown female infant.

[57] VPRS 24/P0, Unit 88, Item 1860/1123, unknown male; VPRS 24/P0, Unit 73, Item 1859/1106, unknown male; VPRS 24/P0, Unit 68, Item 1859/599, unknown male.

[58] VPRS 24/P0, Unit 141, Item 1864/320, James S. Durop.

[59] Valerie Lovejoy, ‘The things that unite: inquests into Chinese deaths on the Bendigo goldfields 1854–65’, Provenance, no. 7, 2006, p. 17. See also Keir Reeves and Benjamin Mountford, ‘Court records and cultural landscapes: rethinking the Chinese gold seekers in central Victoria’, Provenance, no. 6, 2007, pp. 30–41; Kevin Wong Hoy, ‘Murder, manslaughter and affray: making a cold case of the Buckland Riot, 4 July 1857’ in Keir Reeves and David Nichols (eds), Deeper leads: new approaches to Victorian goldfields history, BHS Publishing, Ballarat, 2007, pp. 131–155.

[60] Herald, 2 December 1871, p. 1, and 20 December 1872, p. 4; Nicole Davis, ‘Personalities of the arcades: Fong Fat, Chinese merchant in Melbourne’s Eastern Arcade, part one’, 8 November 2018, available at <>, accessed 3 November 2020; Nicole Davis, ‘Personalities of the arcades. Fong Fat, part two: a Chinese–Australian family in Melbourne, 10 May 2020, available at <>.

[61] VPRS 24/P0, Unit 167, Item 1865/202, Ah Chow; ‘Inquests’, Leader, 15 July 1865, 2.

[62] ‘The coroner: sudden death’, Herald, 9 May 1870, p. 3; ‘Inquests’, Argus, 11 May 1870, p. 7.

[63] VPRS 24/P0, Unit 239, Item 1870/379, Fong Fah.

[64] ‘Summary of news’, Border Watch, 21 May 1870, p. 3.

[65] Births Deaths and Marriages Victoria, see records: Ah Chow, death, 7051/1865; Quinti Fong Fat, death, 4910/1870; Catherine Downing and Fong Fat, marriage, 754/1871; Catherine Fong Fat, death, 5148/1884; Fong Fat, death, 15719/1887.

[66] Kate Bagnall, ‘Rewriting the history of Chinese families in nineteenth-century Australia’, Australian Historical Studies, vol. 42, no. 1, 2011, pp. 62–77.

[67] For Chinese women in NSW in the period, see Kate Bagnall, ‘Chinese women in colonial New South Wales: from absence to presence’, Australian Journal of Biography and History, no. 3, 2020, pp. 3–20.

[68] VPRS 24/P0, Unit 369, Item 1877/387, Esther and Julien Emanuel Jacobs Marks; ‘The St. Kilda disaster’, Age, 18 December 1877, p. 3. Average household size in Victoria from 1840 to 1900 declines from around 14 in 1840 to five by 1900.

[69] For a broader discussion of court records and archives, see Ann Genovese, Trish Luker and Kim Rubinstein (eds), The court as archive, Australian National University Press, Acton, 2019.

[70] Amato, Jacob’s Well, p.12.

[71] Holly L. Crossen-White, ‘Using digital archives in historical research: what are the ethical concerns for a “forgotten” individual?’, Research Ethics, vol. 11, no. 2, 2015, pp. 108–119. See also Gavan McCarthy and Helen Morgan, ‘Rights and the commons: navigating the boundary between public and private knowledge spaces’, in M Moss, B Endicott-Popovsky and MJ Dupuis (eds), Is digital different? How information creation, capture, preservation and discovery are being transformed, Facet Publishing, London, 2015, pp. 171–187.

[72] Greg Dening, ‘Past imperfect’, Australian Review of Books, April 1998, p. 5.

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