In the early twentieth century, the coroner was an official appointed by the Crown to organize and conduct inquests into violent or suspicious deaths. The individuals appointed as coroners possessed diverse backgrounds. Often, such appointments were based as much upon the candidate’s knowledge of medicine and law as they were upon their political affiliations. The coroner was free to select any venue to serve as a “courtroom,” so long as it afforded enough space to accommodate the jurors, experts, officials, and witnesses, and often the bodies of the deceased. The inquest held the day after the deaths of Ada and Clifford Redpath, for example, took place in the family mansion. Coroners selected and swore-in the jurors under oath, examined the experts and witnesses, and compiled key medical reports, like autopsies.

A written copy of the testimony and verdict was prepared on special forms, and often transcribed in real time at the inquest by an officer of the Crown. Such transcriptions had the potential to introduce errors into the testimony of the experts and witnesses. Ultimately, coroner’s inquests served to determine whether the death or deaths were natural, unnatural, or criminal. In the case of a death found to be criminal in nature, the coroner’s inquest would lead to judicial proceedings aimed at identifying the guilty party or parties.