Police have been told they could have done more to protect a vulnerable woman who was burnt to death by her estranged husband.
But the Victorian coroner says no one was responsible for the death of Sargun Ragi except her husband, Avjit Singh.
Singh breached an intervention order several times before he tracked his wife down, cut her throat and set her on fire on October 4, 2012.
Singh also caught fire and died in hospital later that day, but it's unclear whether his death was intentional.
"This is a shocking case of family violence perpetrated by a man seemingly determined to exact vengeance on a woman who had obtained the protection of an intervention order," Coroner Ian Gray told the Coroners Court on Friday.
"Ms Ragi had done all she could to ensure her own protection from her husband, Mr Singh, through the legal system. It was to no avail."
The couple married in India about a year before they separated, while living in Melbourne, in August 2012.
An intervention order was made at the time after Ms Ragi, 23, told police Singh would lock her in their home, did not feed her and threatened her with deportation if she did not have sex with him.
Mr Gray said Singh, 31, telephoned Ms Ragi several times over the next month.
Ms Ragi reported some breaches to the police and was twice told she needed to attend a station to make a formal statement.
The police did not lodge new risk assessment reports after those calls and their response was to phone Singh twice.
Mr Gray said Singh could have been arrested and found there was a failure to see the bigger picture.
"The lesson from this case is that telephone breaches can, in fact, be clear evidence of escalating risk to a person protected under an intervention order," he said.
Mr Gray noted that none of the system flaws contributed to Ms Ragi's death and no one was responsible except Singh.
Singh used a wrecking bar to break into Ms Ragi's Kew East home and then attacked her with a knife, before setting her on fire.
Mr Gray recommended that the state government create a family violence advocate service and develop education programs for men who inflict family violence.
He said police who submit risk assessment reports after a family violence incident should review previous reports that relate to the offender.
Comment was being sought from Victoria Police.
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