Coroner Garry Evans displayed both courage and intelligence in his findings into the deaths of twins Chris and Cru Kahui.
If the police case pointed the finger of blame at their father, Chris Kahui, Evans' 77-page report shakes a fist. Kahui was acquitted by a jury of murdering the twins, but the inquest, which could not, under law, commence until the criminal charges were disposed of, leaves no doubt as to who the coroner thinks was responsible.
The twins died, Evans said, "whilst they were in the sole custody, care and control of their father". Kahui's behaviour on the day the twins died was "incompatible with what might reasonably be expected of a caring father with nothing to hide" - those last four words are both chilling and telling - and his evidence had been "unreliable, conflicting and on many occasions untrue". It is hard to imagine a more damning choice of words.
The coroner's finding does not amount to a verdict that Kahui is guilty of murder. Murder must be proven, beyond reasonable doubt, to the satisfaction of a jury.
A coronial inquest is not a criminal trial but what is known as an inquisitorial hearing: it determines facts but does not find guilt. And it is here that Evans' finding is both bold and provocative. In finding how the twins came to meet their deaths he did not - indeed, legally may not - find that Kahui bore criminal responsibility. But interestingly, he said that he was "satisfied to the point of being sure" of his finding.