Bullet casings which should have provided an insight to Edward Livingstone's mindset and access to firearms were discarded by the police officers who were handed them by his estranged wife, it has been revealed.
During a supervised visit, Livingstone had presented a number of spent rifle casings to his children, ostensibly as gifts.
Livingstone later used a stolen shotgun in January last year to kill Bradley, 9, and Ellen, 6, Livingstone in the Kiwi St, Dunedin, house they shared with their mother, his estranged wife, Katharine Webb. Livingstone then turned the gun on himself.
Southern district commander Superintendent Andrew Coster confirmed yesterday the officers who were handed the casings by Ms Webb had taken it upon themselves to dispose of them without consulting their superiors or recording the matter.
In her findings into the deaths of Livingstone and the children, Chief Coroner Judge Deborah Marshall said the casings presented a "clear red flag".
Mr Coster said Southern police accepted the coroner's findings and that police had failed in their duty of care to Ms Webb and her children.
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.
She separated from him shortly after and sought a protection order which was first issued on May 31, 2013, and finalised on August 13.
Livingstone first breached the order on August 7 and it was while police were attending this breach that they were made aware of the bullet casings.
The attending officers failed to record that Livingstone had handed the casings to the children and the opportunity to investigate his access to firearms was missed, Mr Coster said.
"My expectation would be, in a situation like that, we would consider 'does that tell us something about the subject's access to firearms'," he said.
"A lot of this is about judgment." Mr Coster said the measures implemented by Southern police, since the tragedy, would prevent the same failings from recurring. However, he stopped short of saying the tragedy could have been averted.
"It is far from clear that even if the police response had been textbook that we would have prevented what happened in this case," he said.
Dunedin police dealt with 2000 cases of family violence every year and it was a challenge to identify the cases which presented the risk of tragedy, he said.
Judge Marshall said the Family Violence Inter-agency Response System (FVIARS) partners, which met to discuss family violence cases, also missed the "red flag" of the bullet casings.
Despite the casings not being recorded, the incident did come to the attention of the FVIARS partners.
"There were lost opportunities in the actions taken by FVIARS," she said.
"The cartridge cases were apparently discussed at one of the meetings yet this incident, although a clear red flag, was not noted in the minutes and no specific action was minuted. Police could have been tasked to interview Edward and his access to firearms could have been investigated."
Police were also aware of the rape incident and yet did not pursue it because Ms Webb had indicated she did not want to lay a complaint.
An adult sexual assault team was established in Dunedin following the Livingstone case and police now took a more proactive approach in investigating incidents of adult sexual assault, Mr Coster said.
Police acknowledged the courage of Ms Webb and "extend our utmost sympathy to Katharine for her loss in this situation".
Mr Coster became the Southern district commander only months before the shootings and it made him question whether police had done enough to protect the children. "Any case like this shakes you and makes you question whether we are doing everything we can do," he said.
"Much as we deal with difficult things all the time, it doesn't fully prepare you for when something like this goes wrong - it's difficult."
As a result of the tragedy, police, along with FVIARS partners, reviewed the structure and planning of their meetings and implemented a new system.
• Edward Livingstone was competent to make his own decisions and appeared to be "hedging his bets" until the final decision to kill his children and himself.
• Livingstone died from a single self-inflicted shotgun wound to the chest.
• Bradley Livingstone died from three shotgun wounds at the hands of his father, Edward.
• Ellen Livingstone died from a single shotgun wound at the hands of her father, Edward.
• Health professionals need to take care when providing reports to a court. They should be aware of what the report will be used for and advise the court of the report's sources and any limitations.
• Police should provide training to family violence specialists and frontline officers that reinforces the seriousness of any incident of family violence.
• Police should review how incidents of family violence are recorded and ensure the information is kept in a readily accessible central repository.
• Police should review whether the adult sexual assault regime put in place in Southern district should be implemented nationally and the Southern district's regime should be audited.
• The Family Violence Inter-agency Response System partners should regularly audit the way in which cases are chosen for discussion, what information is presented at meetings and what actions are taken after meetings.
Vengeful act plotted for months
The ultimate manipulator, Edward Livingstone had prepared his vengeful plot for months.
A key to the flat the Department of Corrections employee once shared with co-worker Philip Mans went missing shortly after the pair moved into the house in June 2013.
Livingstone moved out in January 2014, days before he shot his children as they slept in their beds.
Mr Mans, a hunter, kept a gun cabinet in the house. The missing key was later used by Livingstone to access the house to take the Stoeger shotgun he used to kill his children.
Mr Mans did not speak of Livingstone as an insane man, but a manipulator who "played" him to gain access to his firearms.
During the inquest into the death of Livingstone and his children Bradley and Ellen, Anne Stevens, counsel for the children's mother, Katharine Webb, said the evidence painted a picture of Mr Livingstone as a duplicitous individual who was "deliberately deceiving" healthcare professionals.
Ms Webb told police after the shootings that Livingstone had told her of how his friend had spiked his drinks once, causing him to fail an exam. A year later, Livingstone got his revenge by doing the same thing to the friend.
"He said he bided his time," she said. "And I think that's what he's done. I think he's worked out what he was going to do, waiting for my guard to go down and I think he's shot the kids."
To many, Livingstone appeared to be a normal father, struggling to cope with the separation from his wife.
But, to those who knew him, he was never a family man.
Ms Webb's sister, Genevieve Webb, told police Livingstone lacked "social norms" and "struggled to be a father".
Livingstone was born in Christchurch and his parents separated when he was young. His mother, Evelyn, left for England and had little to do with Livingstone or his sister, Suzanne. He moved to Australia and was raised by his father, a reportedly violent man, from about the age of 7. His father once dragged him out of bed, broke his nose and his thumb and split his head open.
Livingstone's sister was sexually assaulted by their father's friends when they were drinking.
Whatever caused his difficulties, Livingstone was withdrawn from his children and his mood changed after the birth of Bradley, Ms Webb said.
On the day of the shooting, he wrote a note: "Why couldn't Kath just let me see & spend time with my children! That's all I wanted." He revealed the true intent of his actions when he sent a text message later that day to Ms Webb's neighbour, Christopher Foot: "Look after yourself, karma will get Kath".
On January 15, 2014, Livingstone bought petrol for his car and purchased an extra quantity in a red plastic petrol canister.
That night he took the shotgun and petrol to Ms Webb's St Leonards home with the intention of killing his children and himself, and burning the house down. He entered Ms Webb's bedroom first, startling her and sending her fleeing from the house. He then shot the children, before becoming involved in a confrontation with Mr Foot. He shot at him but missed and then turned the gun on himself.
Expert welcomes move to encourage sharing of information
A leading family violence expert is welcoming a move to encourage more transparency between agencies dealing with domestic abuse cases.
Rob Veale, a retired police officer and specialist adviser on domestic violence awareness, said a reluctance to share information was compromising investigations.
"Organisations don't feel comfortable sharing information and [meetings between them] focus on police information, rather than what's in the domain of other organisations."
Mr Veale said the fact that Edward Livingstone had given bullet cartridges to the children as a present months before the incident, as well as the fact that Livingstone's estranged wife, Katharine Webb, had reported he had raped her, highlighted flaws in the system.
"We all make mistakes, but those were two salient types of behaviour that should have signalled a review of what the [Family Violence Interagency Response System] was looking at." It was unacceptable the bullet cartridge incident was not known about by the whole group.
"The information-sharing protocol should facilitate information from all parties - not just police."
Mr Veale lamented the fact diversion had been granted for "minor family offences" committed by Livingstone, even though they breached a protection order preventing him from contacting Ms Webb. "This is not a question of warnings; the question is, 'How many days are you going to do in prison?'
"Government quadrupled the maximum penalty for these offences [from six months to two years], yet people are still dealing with this and calling them 'minor'."
University of Otago law faculty dean Professor Mark Henaghan echoed Mr Veale's comments.
"Sadly, this [report] reflects something we've seen before. We are still not taking the signs of violence in the home seriously enough. Why do we just let things roll on, hoping everything will be all right?" The recommendation for increasing transparency between parties was "bang on", Professor Henaghan said.
"We should be doing a lot better. Each incident is looked at in isolation. There is no co-operation."
Countdown to murder
Wednesday, Jan 15, 2014
Edward Livingstone texts his new partner, Karen Wright.
Livingstone again texts Ms Wright.
Livingstone fills a script for nicotine patches and antidepressant medication in Milton.
Livingstone leaves a message on the answerphone of his Family Court lawyer, Lynne Harrison.
Livingstone buys a red plastic fuel container from Mitre 10 Mega in Dunedin.
Livingstone buys beer and cigarettes in Dunedin.
Livingstone attends his supervised visit with Bradley and Ellen Livingstone at Barnardos Dunedin.
Livingstone's meeting with the children concludes with kisses and cuddles.
Livingstone buys petrol in Mornington for his car and fills the red fuel container he bought earlier.
Livingstone begins another text conversation with Ms Wright.
Livingstone texts Ms Webb's neighbour, Christopher Foot.
Livingstone arrives at the Kiwi St home he previously shared with his children and their mother, Katharine Webb. Livingstone is carrying a stolen shotgun, ammunition and the fuel container.
Livingstone shoots his children, killing them.
Police are called. Livingstone is found dead with the shotgun next to him by Mr Foot.
Armed offenders squad members enter the house, finding three bodies.