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The inquest into the deaths of Edward, Bradley (9) and Ellen (6) Livingstone was held in Dunedin this week. It provided a chilling insight into Edward's mind and exposed failings in the handling of his case by those charged with protecting the children and their mother, Katharine Webb. Timothy Brown looks at key testimony from those who gave evidence.
Mother of Bradley and Ellen Livingstone
• Edward Livingstone had mood swings and insomnia, which started in October 2012. He grew needier and did not ''like me going away''.
• Livingstone confided to Ms Webb that he had an earlier conviction in Australia. But, at the time, she believed everyone deserved a second chance.
• About Christmas 2013, he cancelled house and car insurance on property the couple had previously shared.
• Livingstone breached the protection order other times, but Ms Webb did not know if they were ''serious enough'' to report.
• On May 15, 2013, she ended her relationship with Livingstone after he raped her earlier in the month. Livingstone blamed Zyban - a drug used to treat depression and aid smoking cessation - for the attack.
• Livingstone gave bullet casings to his children as a gift. Ms Webb felt he did it to send her a message.
• Ms Webb thought Livingstone slashed her car's tyre during another unreported breach of the protection order.
Ms Webb's neighbour
• Livingstone texted Mr Foot on the night of the killings that ''karma will get Kath''.
• Mr Foot confronted Livingstone during the frenzy and was ''going off my nut at him, screaming at him''. Livingstone seemed ''in a daze''.
• Livingstone told him: ''It's got nothing to do with you, Chris - just get out of here''.
• Livingstone fired a shot at Mr Foot, but missed.
Ms Webb's neighbour
• In May 2013, Ms Webb visited Ms Foot and told her Livingstone had thrown a table and tipped rubbish over her. She also disclosed Livingstone had raped her.
• Livingstone lived with the Foots briefly in June 2013. His behaviour was ''scary'' and he was observing Ms Webb.
• On one occasion, Livingstone said he planned to kill Ms Webb and his children with the back of an axe. He would then overdose on sleeping pills, lay them in bed together and set fire to the house.
• Mr Foot told his wife Livingstone said ''the f... b... was going to get a bullet'', referring to Ms Webb.
Edward Livingstone's acquaintance
• Livingstone stayed with Mr Fleming and his wife briefly in mid-2013.
• The day after meeting Mr Fleming for the first time, Livingstone told him he was molested as a child and thought about killing his children ''but the pills stop me, so I probably wouldn't''.
• Livingstone was asked to leave the house after the incident.
Work and Income New Zealand southern region director
• Work and Income's handling of Ms Webb's family violence concerns was ''exemplary'' before and after the events of January 15, 2014.
Child, Youth and Family Dunedin site manager
• The Livingstone family was discussed at Dunedin Family Violence Inter-Agency Response System (FVIARS) meetings on three occasions.
• It was never considered that there was an escalating risk to Bradley and Ellen.
• The children were seen as protected by their mother and she was doing all she could to keep herself, and them, safe.
Dr Christopher Wisely
Edward Livingstone's psychiatrist
• Livingstone first came to the attention of the Southern District Health Board in August 2006 after a ''major depressive episode'', which had worsened after the birth of Bradley in 2004. He was drinking ''quite a lot''.
• He presented to emergency psychiatric services on May 23, 2013, after he forced his wife to have sex for five hours.
• Dr Christopher Wisely first met Livingstone in July 2013. He complained of an ''unpleasant recurring dream''.
• Livingstone told Dr Wisely about his childhood. His mother left when he was 3 and he did not know his father until he was 7. His father was abusive; he ''dragged him out of bed, broke his nose on one occasion, broke his thumb and split his head open''. Livingstone's sister was also subjected to abuse. Their father's friends sexually assaulted her when they were drinking.
• Livingstone - with his new partner - last met Dr Wisely on January 13, 2014. The forced sex was discussed and his new partner wanted to know if he was ready for a relationship. He was ''friendly and smiling and joking''.
Sergeant Kate Saxton
Prosecutor of Edward Livingstone's second protection order breach
• Sergeant Saxton learned on November 13, 2013, that Livingstone was known to Australian police.
• On November 15, 2013, Livingstone was discharged without conviction for breaching a protection order. Police opposed the outcome, but Sgt Saxton did not disclose the Australian police's dealings with Livingstone.
• On December 9, 2013, Interpol advised Dunedin police Livingstone had two convictions in Australia - for arson and assault - from 1988.
• Sgt Saxton conceded Livingstone's breach was not minor, as the district court had heard, but instead had a ''very serious impact'' on his estranged wife.
• Police also mistakenly granted diversion to Livingstone for his first breach of the protection order.
Witness A (name suppressed)
The Foots' acquaintance
• Witness A called police about Livingstone's behaviour because she was concerned for Mrs Foot.
• Livingstone was ''obsessive'' about his estranged wife and his behaviour was ''creepy''.
Dr Coleen Lewis
Edward Livingstone's GP
• Livingstone was seen infrequently by Dr Lewis between 2006 and 2013.
• She last saw Livingstone on June 10, 2013. He felt ''he has been to hell and back''. Livingstone appeared ''calm and reasonable''.
• The events of January 15, 2014 ''came as a surprise to me''.
Barnardos Dunedin receptionist
• Ms Rowe spoke with Livingstone on January 15, 2014, about future supervised visits with his children.
• He appeared ''relaxed and happy''.
''There was nothing I can see that indicated he was going to do what he did later that night.''
Detective Senior Sergeant Kallum Croudis
Officer-in-charge of the investigation into the deaths of Edward, Bradley and Ellen Livingstone
• Dunedin police first came into contact with the Livingstone family on May 27, 2013, after a domestic incident between Livingstone and Ms Webb. At that time, police were told by Ms Webb that Livingstone had raped her about three weeks earlier.
• On May 31, 2013, a temporary protection order was served on Livingstone.
• Livingstone emailed Ms Webb on August 6. He phoned her the following day and neighbour Melanie Foot saw Livingstone at the house. Ms Webb saw him driving in the area that night and police were called. Ms Webb gave police a number of bullet cartridges which Livingstone gave his children as a present. Police disposed of them and did not speak to Livingstone about them.
• On August 14, 2013, during an interview with police, Livingstone said he had been convicted of arson in Australia. Police did not follow up the matter. Livingstone was charged with breaching a protection order.
• Livingstone received diversion, without conditions and against police policy, on September 4, 2013.
• Ellen died from a single blast of a shotgun, while three discharges were apparent in Bradley's body. Livingstone died from a single shot.
• A succession of failures by police led to a situation where Livingstone was able to kill his children.
• It was ''possible - probable, even'' - that Livingstone could have been imprisoned for raping his wife if police gave the matter more weight.
Department of Corrections senior human resources adviser for Otago and Southland
• Livingstone did not disclose his convictions, for arson and assault in Australia in 1988, to Corrections, his employer. The department did not know until after Livingstone's death.
• Managers were aware of Livingstone's personal issues before August 2013 and offered help, but he declined.
• On August 8, 2013, Livingstone told Corrections he was arrested for breaching a protection order - this was how Corrections learned of the order.
• On September 18, 2013, he advised he breached the order again and was stood down by Corrections two days later. He appeared dishevelled and smelt of alcohol at work before the offending. He returned to work on October 14, 2013.
• Corrections learned on November 15, 2013, Livingstone was discharged without conviction. In December, he was issued with a final warning by Corrections.
Dr David Chaplow
Serious adverse event clinical review convener
• Livingstone was ''hedging his bets'' before the killings, but was thinking of acting on his homicidal thoughts ''hence stealing the gun, stealing they key''.
• A number of ''red flags'' came to the attention of the clinicians dealing with Livingstone, but the slayings were ultimately unavoidable.
• Livingstone spoke to his new partner, Karen Wright, while drinking on a park bench little more than an hour before he shot his children. He was feeling ''quite morose''.
• Livingstone would ''impression manage'' to deceive his clinical carers.
Barnardos Dunedin contact supervisor
• Bradley and Ellen were anxious before their first supervised meeting with Livingstone. During the meeting the children ''were quiet and withdrawn''.
• His expressions of love, during the five meetings Ms Cadogan supervised ''appeared to be a performance rather than a genuine reaction''.
• During one visit, Livingstone became confrontational and '' it showed he could be quite unpredictable''.
• She never saw Livingstone physically hurt the children, but he appeared emotionally manipulative.
Edward Livingstone's former flatmate
• Mr Mans felt Livingstone manipulated him to get his firearms.
• Livingstone drank until he would ''stumble into the house''. He drank up to ''six large beers'' in a sitting.
• Livingstone went shooting with Mr Mans to sight a rifle. He did ''not like the shooting at all'', but collected the used bullet casings. Mr Mans did not know why.
Witness B (name suppressed)
Edward Livingstone's psychotherapist
• Witness B agreed Livingstone appeared to ''impression manage''.
• He was careful about what he shared and the image she got was of a man who ''was going through a really difficult time''.
• Livingstone was upset his estranged wife portrayed him as ''violent, alcoholic nutter''. He believed he was a sex addict.
• Livingstone had narcissistic personality disorder and a high sense of self-entitlement.
• At meetings of Dunedin's FVIARS partners, Livingstone was assessed as ''high risk''. However, it appeared no further action was taken because of the assessment.
Superintendent Andrew Coster
Southern district commander
• On May 27, 2013, police were called to the family home and told by Ms Webb that Livingstone had suicidal thoughts. He spoke about hanging himself or jumping off a cliff.
• During this callout, police were told by Ms Webb that Livingstone had raped her for five hours. Her daughter was at the bedroom door crying at times and Livingstone stopped Ms Webb from tending to her. Attending officers notified CIB but there is no detail of recordings of the allegation by attending CIB staff. A police file for the rape was not created.
• On August 15, 2013, FVIARS partners agreed the Livingstone case was ''high risk'' but took no additional action.
• The decision to grant Livingstone diversion for breaching his protection order was a mistake. A national audit uncovered six other instances.
• Police should not have let Ms Webb self-manage the rape allegation.
• Changes were made by Dunedin police following the deaths, including the creation of an adult sexual assault squad in Dunedin and a willingness to progress investigations involving reluctant victims. Staff also receive regular training in handling sexual assault.
• Police failed in their duty of care to Ms Webb and the children.