Lots of crocodile tears here by moronic officials who refused to act on any number of red flag, refused to look at all the evidence, ignored the mother's concerns, and thus allowed two kids be viciously murdered by their father.
Dad is identified as EDWARD LIVINGSTONE.
http://www.stuff.co.nz/national/crime/68011537/killer-dad-edward-livingstone-high-risk
Killer dad Edward Livingstone 'high risk'
A Dunedin inquest into the deaths of the Livingstone children has ended with top officials fighting back tears.
Bradley, 9, and his sister Ellen, 6, were shot dead by Livingstone at their home in the Dunedin suburb of St Leonards, shortly before 10pm on January 15 last year.
Livingstone, 51, was later found dead in the front bedroom of the house at 9 Kiwi St.
A shotgun lay next to him.
He left a final note at his flat before the killings.
Katharine Webb, Livingstone's former wife and the mother of Bradley and Ellen, was the first of 18 witnesses called to give evidence at an inquest into the three deaths, which began on Tuesday in Dunedin.
She escaped the shooting unharmed.
OFFICIALS EMOTIONAL AS INQUEST CLOSES
Chief Coroner Deborah Marshall on Friday closed the inquest and reserved her decision.
She thanked Katharine Webb for her quiet dignity.
It reminded everyone "how much you have suffered", Marshall said, voice breaking.
Shortly before, Southern District Commander Andrew Coster underlined the emotional weight of the inquiry by also fighting back tears as he defended the police performance under a grilling from Webb's lawyer Anne Stevens.
Police were "totally committed" to do better but "we can't change what happened", he said.
Coster said he had moved to close the cracks the Livingstone case had highlighted and more resources had been allocated to family violence in the district.
Police received 2000 family violence reports per year just in its Dunedin office.
Coster said if Livingstone's convictions in Australia from 1988 (arson and assault) had been known to the court dealing with his protection order breach, it was still questionable whether it would have made a difference.
At the time of the hearing, police still needed to know more about the convictions and the circumstances.
He said the information had come from a cell interview for intelligence purposes and entered into the police intelligence system..
If the officer he had known more detail about the case, it might have been an error not to have taken further action.
In a best case scenario, a family violence meeting co-ordinator would have noticed the new information and followed it up.
The police prosecutor who opposed a discharge without conviction for Livingstone's second breach of his protection order could have sought an adjournment to investigate further his convictions in Australia.
"It's most likely it would have been granted."
Two constables who attended an incident at Livingstone's house on August 7 and were handed empty bullet shells which Livingstone had given his children, should have recorded it.
"It was a very significant matter and staff did not attach sufficient weight to it."
The fact police did not investigate a rape allegation by Webb was a failure and too much reliance was placed on Webb's desire not to take it further.
Police and other agencies did have a level of awareness of risk factors in the case and "there were a lot of things in place that led this group to believe the case was well managed."
Nothing of great significance suggested an major escalation of risk, he said.
"But if the police had taken ownership of the rape there is a distinct possibility we would not be here?" Stevens said.
Police would have needed a reliable confession from Livingstone to proceed with a prosecution if his wife did not want to pursue charges.
"I accept if convicted he would be in custody."
He agreed complainants could change their mind.
Webb had engaged with Women's Refuge, she had a protection order, Livingstone had engaged with Emergency Psychiatric Services and the children were in a programme.
He was not sure much more could have been done.
"You can't make the right call in every instance."
Even if Livingstone had not received a discharge without conviction, he would almost certainly not have gone to prison, Coster said.
But each little step made here ultimately affected the outcome, Stevens said.
Coster said it was unfair to assume outcomes would have been different if the case was handled better.
In other evidence, Mel Foot, who lived next door to the Livingstone house, remained adamant she had telephoned police in August to tell them about a threat Livingstone made to kill his family with an axe.
She had also told two constables who attended an incident at the Livingstone house on August 7.
"I'd warned everybody but nobody listened."
Coster said police were unable to verify Foot's claim.
LIVINGSTONE WAS 'HIGH RISK'
On Friday, former Dunedin probation officer Liqueshia Dougherty told the inquest she was briefed about Livingstone at an inter-agency family violence meeting about a week after he had breached a protection order on August 6, 2013, preventing him from contacting Webb.
The meeting was attended by several agencies including Police, Corrections, Child, Youth and Family and Women's Refuge.
Dougherty noted on a document that she was told Livingstone was considered "high risk" and had narcissistic personality disorder, a high sense of entitlement and refused to accept his relationship with Webb was over.
She also noted that he had given his children bullet casings at a supervised visit as a "message for her [Webb]".
It was brought to her attention that Livingstone worked at Otago Correctional Facility and she made a note so she could pass it on to management at the prison.
"At the time it seemed like I was the only person in the room that wasn't aware of the information.
"Everybody seemed quite concerned. People felt there was more underneath it."
Dougherty said the reference to the bullet casings made her particularly concerned.
She did not recall knowing anything about an allegation that Livingstone had raped Webb.
Minutes of the meeting noted there had been two family violence incidents involving Livingstone and Webb, most recently on May 27.
They also noted that Livingstone had mental health issues and Women's Refuge was working closely with Webb who had written about wanting to end her relationship.
Livingstone's name was added to a high risk register.
People on that register were "kept a closer eye on", Dougherty said.
It indicated an issue that needed more intervention.
There were 31 new family violence related matters discussed at the meeting.
KEY POINTS FROM DAY ONE
* Katharine Webb said Edward Livingstone raped her in May 2013 shortly before they separated. She did not pursue charges because she wanted to focus on getting out of the house and keeping her children safe. She knew where to go for help if needed.
* In 2013, Livingstone twice (August 6-7 and September 14) breached a protection order preventing him from contacting Webb in the months before the shooting. He obtained police diversion on one charge and a discharge without conviction on the other.
* Livingstone had an historic conviction for arson in Australia dating back to 1988. The court heard he set fire to his former fiance's home after coming home to find her in bed with another man.
* Livingstone gave bullet casings to his children during a supervised visit after he separated from Webb.
* Livingstone told associates he had thoughts about killing his family and himself in the months before the shooting. Livingstone's neighbour Mel Foot said she contacted police in August 2013 and told them that Livingstone had talked about killing his family. Foot alleged the complaint was never followed up by police.
* Psychiatrist Christopher Wisely was unaware of Livingstone's historic conviction for arson or the incident involving the bullet casings. If Wisely had known it may have altered the risk assessment he gave to a judge at a sentencing hearing at Dunedin District Court on November 15, 2013, in relation to the second breach of the protection order. Livingstone was discharged without conviction.
* Police prosecutor Sergeant Kate Saxton said she was not fully aware of Livingstone's criminal offending in Australia at the time of the hearing. She could have sought an adjournment on the matter until she was sent all the information, but decided not to. Interpol sent her a copy of Livingstone's Australian criminal history on December 9. Saxton conceded that the information could have altered the outcome of the sentencing.
* Saxton also told the court that Livingstone should not have received diversion for the first breach of the protection order. Diversion was not available for breaching a court order, she said.
* Wisely said Edward Livingstone sourced the shotgun used in the shooting from a former flatmate's home. The flatmate did not know Livingstone had taken the gun until police came to his home after the shooting.
KEY POINTS FROM DAY TWO
* Southern District Commander Andrew Coster said police had failed to pick up red flags in the case and the Criminal Investigation Branch should have investigated an allegation, admitted by Livingstone, that he had brutally raped his wife Katharine in May, 2013. The police effort was well intentioned but inadequate and too much weight had been given to Katharine Webb's wishes. Livingstone should not have been considered eligible for diversion and police should have pursued the allegation despite the victim's desire not to pursue the allegation. Steps had been taken to address the failures, he said, with a specialist investigation unit set up.
* Detective Senior Sergeant Kallum Croudis, of the Dunedin police, admitted a series of significant failings by police staff who dealt with Livingstone and his family in the months before the shooting. Police had failed to follow-up in a timely way information Livingstone had an arson conviction in Australia. Bullet casings Livingstone gave to his children at a supervised visit and then handed to police should have been investigated.
* Livingstone drove to the Kiwi St property with a red fuel container full of petrol, a shotgun stolen from his former flatmate and ammunition. There were beers in the car, but blood tests would later show he was not over the legal limit. Livingstone entered the house through a side door using a key before shooting his children in their bedrooms.
* Police investigations showed Livingstone claimed he was abused at a boys' school in Sydney and had a violent father. His mother left the family when he was very young. He has a younger sister called Suzanne.
* Police received information, probably on August 8 last year, that Livingstone was harassing his former wife's neighbour by phone calls and text messages mainly wanting to know if his wife was still wearing her wedding ring. Police were also told Livingstone was sneaking around his former family home when his wife was at work. The informant (name suppressed) told police Livingstone was, "f...... nuts".
* The general practitioner treating Livingstone says she doubts the drugs she prescribed on May 16, 2013 (zyban and escitalopram) could have caused a psychotic episode leading him to rape his wife. He had not reported problems with past use of zyban. Livingstone's psychiatrist Chris Wisely believes Livingstone had an adverse reaction to the drugs that led to the rape his wife. The couple separated after the rape.
KEY POINTS FROM DAY THREE
* Livingstone deceived his psychotherapist by not telling her fully about his past or the full details of the incidents relating to his first breach of a protection order. The psychotherapist, whose name is suppressed, did not seek details of the police case and provided a letter, which was later produced in court, saying she did not believe Livingstone was a violent man, despite knowing he had raped Webb. Livingstone once told the psychotherapist he was a "sex addict".
* Barnardos employee Rebecca Cadogan, who supervised five of Livingstone's six arranged visits with Bradley and Ellen, said she was not surprised to learn he had killed his children. Cadogan said she had seen Livingstone become very aggressive and dominating during one of the sessions and instinctively thought of him when she heard about the shooting.
* Former flatmate Philip Mans said Livingstone's drinking increased while they lived together to a point, in the months before the shooting, where he could hardly stand some evenings and went to bed very depressed. Livingstone stole the gun used in the shooting from Mans' locked gun safe. Mans said he felt Livingstone had deceived and manipulated him.
* Forensic psychiatrist Dr David Chaplow said a clinical review identified that elements of Livingstone's care were inadequate. The review's main finding was that information held by various clinicians about Livingstone could have been shared better. Collectively they failed to ascertain Livingstone's danger to Webb. He had deceived them. However, while Livingstone's care could have been better, the review found there was nothing clinicians could have done to change the end result.
* Mark Godwin, from the Department of Corrections, said during Livingstone's recruitment for a job at Otago Correctional Facility checks indicated he had no criminal convictions, nor did he declare any. If the department had been aware Livingstone had an historic conviction for arson in Australia he may not have been hired. In December 2013, Livingstone received a final warning from Corrections after he was was discharged without conviction for breaching a protection order. If Livingstone had been convicted he may have lost his job, Godwin said.
Coster said Mel Foot's claim she told the police on August 8, 2013, about Livingstone wanting to kill his family with an axe emerged through the media.
Police investigated the claim thoroughly but nothing was available to verify the claim.
Police had gone through the calls made by Foot from her telephone and she had accepted no call had been made to convey the information.
She now maintained she had told police in person when officers called at the address on August 7, Coster said..
However the officers had no recollection of that information and believed they would have recorded such a significant thing.
Coster said Mel Foot's claim she told the police on August 8, 2013, about Livingstone wanting to kill his family with an axe emerged through the media.
Police investigated the claim thoroughly but nothing was available to verify the claim.
Police had gone through the calls made by Foot from her telephone and she had accepted no call had been made to convey the information.
She now maintained she had told police in person when officers called at the address on August 7, Coster said..
However the officers had no recollection of that information and believed they would have recorded such a significant thing.