The family of a woman who was stabbed to death by an ex-partner says the state government must make changes to save other women from the same fate.
Victoria's State Coroner John Cain on Wednesday found police missed opportunities to protect Noeline Dalzell before she was brutally murdered by James Fairhall in February 2020.
He had been released from custody three months earlier for breaching a family violence intervention order designed to protect Ms Dalzell.
Among his 11 recommendations, Judge Cain echoed calls from the 2016 Royal Commission into Family Violence for an improved information-sharing system between agencies.
He also called on Victoria Police to carry out an independent review of its family violence units, saying investigators' actions fell short of best practice.
Ms Dalzell's brother Malcolm and sister-in-law Jenny said the government had to implement the recommendations in full.
"The state coroner has given government a road map forward, which if implemented, can help avoid our suffering being repeated," the couple said in a statement.
Fairhall was not allowed to contact or be near Ms Dalzell and their children, but 13 days after his release from jail, he showed up at her home intoxicated and verbally abusive.
Ms Dalzell contacted police, but Fairhall had already left.
A warrant issued for his arrest was never executed.
Instead, Fairhall moved back in with Ms Dalzell from about Christmas 2019 after claiming he had nowhere else to go.
He killed her on February 4, 2020, by reaching over their children to stab her in the neck. He is serving 25 years' jail for her murder.
Judge Cain found police missed opportunities to engage with Ms Dalzell and other agencies to keep her and the children safe.
"The response of the Family Violence Investigation Unit to Mr Fairhall and Noeline from November 6, 2019, until the day of her murder fell far short of best practice," Judge Cain said.
He recommended Victoria Police engage an external independent person to evaluate the effectiveness and skill set of its family violence units.
There should also be better information-sharing between police and government agencies to protect women and children, the coroner recommended.
The royal commission made similar recommendations, leading to the creation of the family violence information sharing scheme and the central information point.
Judge Cain said those systems had improved communication but there were still gaps, with agencies needing to seek out information instead of having automatic access.
The coroner also recommended victims be notified within 48 hours of their perpetrator being released from custody, noting Ms Dalzell was not contacted despite Fairhall being listed as a high-risk offender.
"In order to keep herself and her children safe from Mr Fairhall, Noeline needed to know when he was going to be entering and exiting custody," Judge Cain said.
At the end of his findings, the coroner commended Ms Dalzell's three children for their resilience and extraordinary bravery in the face of persistent violence.
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