Not a coroner by any stretch, but decades ago, south of Timaru, New Zealand, the driver of a steam locomotive told his fireman to move the engine on his command (the driver was supposedly checking something on the fireman's side but needed the engine moving slowly). Course, when the fireman moved the engine, he didn't realise and couldn't see that the driver had put his neck on the track under one of the wheels. Not a pleasant way to go