A coroner investigating the deaths of a woman and her ex-partner in a fire he started has called for urgent reforms to address the "inadequate response" of Queensland police to domestic violence.
Doreen Langham died after Gary Hely started a fire intending to kill the 49-year-old and himself, and set alight her townhouse in Browns Plains, south of Brisbane, on February 22, 2021.
By that time Hely had continually breached a domestic violence order and committed other serious criminal breaches, but no police officer considered his offending significant enough to make any real attempt to find him so he could be questioned and charged, coroner Jane Bentley found.
"It is possible that had every complaint been dealt with in accordance with relevant duties and obligations Mr Hely would not have killed Ms Langham or himself," she said in findings handed down on Monday.
Ms Bentley found the police response to Ms Langham's complaints "was inadequate and police officers failed to protect her and prevent her death".
The experience Ms Langham received "fell far short" of the basic expectations of the police response to domestic and family violence.
Ms Bentley found the poor response indicated a "serious lack of training and consequently understanding of the complex nature of domestic violence by police officers".
Specialists within the Queensland Police had also not recognised the seriousness of Ms Langham's complaints and some reviews did not take place because of a lack of staff.
"A holistic investigative approach would have revealed that Mr Hely had concerning domestic violence history interstate and that the frequency and severity of his behaviour was escalating," she added.
Ms Bentley said officers did not act out of malice, but their "inadequate response was the result of inadequate training and acute understaffing in the Logan district coupled with an ever increasing demand for services".
The coroner called for urgent reforms to address the inadequate response and for the state government to provide funding to trial a specialist victim-centred police station in Logan.
She also called for funding for a domestic violence specialist social worker based at every Logan district police station and recommended officers be required to view the interstate criminal history of suspected domestic violence perpetrators.
Ms Bentley accepted Queensland Police has made efforts to address procedures and training but said multi-disciplinary teams are needed as police alone are not able to deal with domestic violence.
She found the circumstances of Ms Langham's death show police have been unable to implement recommendations made in the 2015 Not Now, Not Ever report on domestic violence.
The coroner said Hely's NSW criminal history indicates he was never held sufficiently accountable in that state either for persistent and serious conduct against previous partners.
NSW records for Hely go back to 2014 and include convictions for stalking and assault.
He had also been the respondent in three final domestic violence orders in NSW.
Hely went to Ms Langham's townhouse complex about 2.30pm the day before their deaths and weeks after their two-year relationship ended.
He was at the front of the home when Ms Langham called police about seven hours later.
Two officers responded about four hours after the call, without looking at any history.
"They failed to fulfil their duties and obligations to investigate the matter and ensure Ms Langham's safety," Ms Bentley said.
"They were at her door for 40 seconds during which they knocked on the door once and then quickly left when there was no answer."
At the time Hely was at the rear of the unit.
He waited for the officers to leave, then another two hours before entering Ms Langham's home.
Once inside the pair struggled before Hely doused Ms Langham with petrol and ignited the fire in the lounge room about 3.30am.
The mother of two, who had three grandchildren, died very soon after the fire began.
Premier Annastacia Palaszczuk said the government will look at the recommendations very carefully.
"But we've had the Women's (Safety and) Justice Task Force already (and) there's additional money for women's safety," she said.
Police Commissioner Katarina Carroll supported Ms Bentley's recommendations saying all levels of government, non-government organisations, businesses and the community need to identify and deliver solutions.
1800 RESPECT (1800 737 732)
Lifeline 13 11 14
Australian Associated Press
Sign up for our newsletter to stay up to date.