The victim of a murder-suicide at the hands of her ex did everything she could to stop it from happening, but Victoria's family violence system let her down.
Kelly Thompson, 43, was sleeping in her Point Cook home when her former partner, Wayne Wood, stabbed her to death with a hunting knife in a murder-suicide in February 2014.
Her death was the subject of a coronial inquest in 2015 and Coroner Ian Gray delivered his findings on Thursday.
Judge Gray found Wood had been considering murder-suicide since October 2013, had always been controlling, possessive and jealous, and had no intention of complying with an intervention order Ms Thompson had taken against him.
During the inquest, the court was told a neighbour called police with concerns the night Ms Thompson was murdered, but no patrol was sent.
Ms Thompson had also called police 38 times in the weeks before her death to report breaches of the order by Wood.
Judge Gray found failings by police to properly record violent incidents and order breaches by Wood.
Police also failed to properly investigate whether charges could be laid against Wood and failed to adequately act on a call by her neighbour.
"Ms Thompson took all the right steps," Judge Gray wrote in his findings.
"The family violence system, as it operated at the time of Mr Thompson's death, failed to recognise that the risks were escalating."
However, he found that despite failings in the system, it was Wood alone who was responsible for her murder and even if police had acted on the neighbour's call, it probably would not have saved Ms Thompson.
Outside the court on Thursday, Ms Thompson's mother Wendy hoped the findings lead to change so her daughter's death would not be in vain.
"It should never have happened, it was preventable, like so many other women it was preventable," she said.
Thompson family solicitor Paula Shelton said it was important that Judge Gray had found Ms Thompson had done everything she could to put an end to the violence she was being subjected to.
"She did everything she could and the system let her down," she said.
Ms Shelton said with Judge Gray's findings and the Victorian Royal Commission into Family Violence, there was now a political will to fix the sector.
Judge Gray made six recommendations, including that front line workers provide all family violence risk assessments to applicants, applicant legal representatives, family violence services, magistrates and police.
He also recommended better information sharing between police and courts.
