It seems to me that character assassination is not in the job description of the coroner.
It is his duty to find out what happened, why it happened, and if he feels it appropriate, to give recommendations on how the same thing can be avoided in future.
If witnesses feel they are going to be subjected to ridicule or shame, they will not be able to be as open and honest as they might otherwise be.
This man has indulged his own prejudices and maybe some personal issues, and has caused a great deal of avoidable anguish for both victims and those who must wish fervently that they had done or not done things which affected the outcome.
Not a good thing for future inquests and one questions who manages this person.