Coroner: What I intend to do is tell you my conclusion in relation to this matter and Peter has paper copies and we’ll send electronically I have to say as I drove home last night and started to review the papers I had a profound feeling I guess of despair about what happened

Coroner: What I intend to do is tell you my conclusion in relation to this matter and Peter has paper copies and we’ll send electronically I have to say as I drove home last night and started to review the papers I had a profound feeling I guess of despair about what happened