Police have made widespread changes to the way they handle family violence cases following the Livingstone shooting, the southern police commander says.
Coroner Deborah Marshall today released her findings into the deaths of nine-year-old Bradley Livingstone and his six-year-old sister, Ellen Livingstone.
Edward Livingstone threatened former wife Katharine Webb on 15 January last year, before shooting his children in their beds in the Dunedin suburb of St Leonards. He was found dead with his shotgun next to him.
Judge Marshall confirmed the circumstances of the deaths but found it was still not clear what triggered his actions.
However she made four recommendations for the police and family violence groups, including that they train all frontline officers and specialists in better risk assessment, and have a central repository for family violence incidents.
She also criticised the way psychiatrist Christopher Wisely and a psychotherapist, who has name suppression, wrote letters to the court playing down Livingstone's violence risk after he twice breached protection orders.
The psychotherapist had said during the inquest she relied upon information Livingstone gave her and on 4 July, after seeing him for 10 sessions, wrote a letter for him stating her belief he was "not a violent man".
She concluded the letter saying: "His love and concern for his family has been at the forefront of his motivation."
But Judge Marshall said she did not agree with the psychotherapist's suggestion courts should be aware they formed their opinions based solely on what their clients told them.
"It is unrealistic to expect all judges to have that knowledge in the forefront fo their mind when reading the myriad reports that may come before them."
However, Judge Marshall concluded better practice by the agencies involved might not have altered the tragic outcome.
Judge Marshall said health professionals should ensure they were aware of the purpose for which reports were sought.
"They should advise the court of the information relied on and its sources and set out any limitations to the report."
She said Dr Wisely had told the inquest the court would have realised two letters he wrote about Livingstone were not full psychiatric assessments.
"I agree that the letters are clearly not full court-ordered psychiatric assessments but, in my view, it would have been helful for the court to know what information was used to form the opinions set out in the letters."
Judge Marshall also recommended that, as part of a police national review of family violence policies and training, all front-line police officers and family violence specialists should be trained to reinforce the message that any incidence of family violence must be treated seriously.
That was because it could be part of a series of incidents which, taken together, would enable a proper risk assessment to be made.
Police Southern District Commander Andrew Coster said the police had made a range of changes to the way they handled family violence cases following the shooting.
He said that included creating a dedicated ASA and Child Protection Team, and training for front-line officers.
Mr Coster said his district had addressed all of the coroner's recommendations, and nationally the police were doing the same.
"We are exercising judgement on difficult cases every day of the week. We won't always get it right, but our goal is to always improve.
"And I believe that the changes we've made will position us well to do that."
Mr Coster said while the police had made many changes, he could not promise the case could not recur.
"When you look at any individual case where something tragic has happened you can often find that there are indicators.
"The challenge for us when we are dealing in Dunedin alone with 2000 events a year is extracting that case out and doing something about it before something bad happens," he said.