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Investigations into the officers who dealt with Edward Livingstone revealed ''systemic failures and issues'' among Dunedin police in the lead-up to the tragic deaths of his two children.
The employment investigations which followed the deaths of Bradley (9) and Ellen (6) Livingstone at the hands of their father uncovered breaches of the police code of conduct by officers, a report about police handling of the case has revealed.
Livingstone was the subject of a protection order when he shot his children on January 15, 2014, with a stolen 12-gauge Stoeger shotgun in the Kiwi St, St Leonards, home they shared with their mother, Livingstone's estranged wife, Katharine Webb.
The report, ''The Livingstone Family Violence Investigation Report: Adequacy of Dunedin police service delivery'', written by then Detective Inspector Virginia Le Bas, now national manager, organised crime, revealed that at the time of the tragedy:
One person within Dunedin police was assigned 200 to 300 family violence files without administrative support.
National policy on intimate partner rape was lacking.
Greater leadership in cases of adult sexual assault and family violence in Dunedin was required.
Officers involved in the case breached the police code of conduct.
The information came to light after the release of a summary of the report to the Otago Daily Times. It was released only after an almost 18-month long fight with New Zealand Police through the Official Information Act process and, subsequently, the Ombudsman.
The Ombudsman earlier this month advised police of his final opinion that the information the ODT requested in July last year was of public interest.
Livingstone and Ms Webb separated in May 2013 and a protection order was issued later that month and finalised in August 2013.
The police became aware of several concerning incidents in relation to Livingstone's behaviour to his family, but they were not followed up.
Livingstone had trapped Ms Webb in her room and raped her for five hours, at times while her distraught daughter banged on the bedroom door, in May 2013. Police were made aware of the incident by Ms Webb but did not investigate further as she did not wish to pursue the matter.
During a supervised visit following Ms Webb and Livingstone's separation, Livingstone presented a number of spent rifle casings to his children, ostensibly as gifts.
Livingstone first breached the protection order on August 7 and it was while police were attending this breach that they were made aware of the bullet casings.
Ms Webb presented those casings to the attending officers but they were discarded.
The attending officers also failed to record that Livingstone had handed the casings to the children and the opportunity to investigate his access to firearms was missed.
Livingstone was granted diversion, against national police policy, for that breach.
He received a discharge without conviction for the second, as the judge was under the impression he had no previous convictions.
Livingstone was convicted of arson and assault in Australia in 1988. Dunedin police became aware of an overseas conviction in August 2013, but the matter was not followed up and police did not find out about the extent of his offending until December 9, 2013 - the month after he was discharged without conviction.
In response to questions about the report summary, Otago Coastal area commander Inspector Jason Guthrie said police acknowledged the issues identified in the report and had ''incorporated those learnings into contemporary practice''.
''Family harm situations are extremely complex and often involve a range of known, and unknown factors,'' he said.
''They also invariably involve a wide range of people and organisations working hard to try and keep people safe so it is impossible to quantify what direct impact police systems and processes at the time had on this tragic outcome.
''As previously spoken about during the coronial inquest into this case, police identified a number of issues in the weeks and months following the deaths of Bradley, Ellen and Edward.''
Police would not comment on how many officers were investigated as a result of failings in the handling of the case or how many code of conduct breaches were identified.
The ODT was previously informed no officers were dismissed or stood down as a result of the case, and police would not comment on whether any had resigned after their involvement in the case.
''Police acted in good faith throughout with the clear intent of keeping people safe,'' Insp Guthrie said.
''Our staff are distraught that Mr Livingstone took the action he did and that all of their efforts, and others, were unable to prevent this tragic outcome.
''The various reviews have highlighted, with the benefit of hindsight, areas where police as an organisation could and should have done better and those points have been acknowledged and we've made significant changes to the way we work.''
The summary of the report provided to the ODT showed Dunedin police had overhauled how family violence was handled in the city.
''In comparison to the previous model in which the FV [family violence] officer consisted of one person who had 200-300 files assigned to it with no admin support, the new FV team model has a case loading of between approximately 15-40 files across the team and a clear case-management practice that identifies risk and ensures appropriate action is taken,'' the summary said.
Four full-time staff, a sergeant and three staff, and an additional team member in a station support officer role now dealt with family violence from the Dunedin South station. Two sergeants in Balclutha and Oamaru were involved in managing family violence in the Otago Coastal area.
A coroner's inquest into the Livingstone deaths in April last year identified shortcomings in the handling of the case by police, social agencies and mental health professionals, which meant ''red flags'' about Livingstone's risk to his family were missed. However, Chief Coroner Judge Deborah Marshall found Livingstone was ultimately responsible for his children's deaths.