Dunedin has had its share of tragedies and needless deaths associated with violence which may have been avoided if signs had been correctly read.
This week, Chief Coroner Judge Deborah Marshall released her findings from the Livingstone inquest and raised some serious concerns about how agencies charged with protecting Katharine Webb and her children acted.
It is not the first time in New Zealand a coroner has raised concerns about agencies missing key warning signs before a tragedy unfolded.
Edward Livingstone was found to be competent to make his own decisions and therefore was ultimately responsible for the death of his children last year.
But multiple failings by police, social agencies and mental health professionals meant the murderous intent of a vengeful father was missed.
Judge Marshall says it is unclear whether the red flags missed by the agencies could have prevented the deaths and there was no doubt Livingstone made his own decisions, including that of ending his own life when challenged by a neighbour.
One of the most damning pieces of evidence to be commented on in the findings was how bullet casings - which should have provided an insight into Livingstone's mindset and his access to firearms - were discarded by the police officers who were handed them by his estranged wife.
Southern district commander Superintendent Andrew Coster confirmed 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.
Given the history of bullet casings being prominent in New Zealand murder inquiries, mainly through the eventual pardon of Arthur Allan Thomas, it should be ingrained into the mind of every police recruit to treat such evidence with respect and as part of a chain of evidence.
While it is easy to be critical, context (as always) is telling. Sadly, Dunedin police deal with 2000 cases of family violence every year.
It is a challenge to identify cases which present the risk of tragedy, Supt Coster says.
Few would disagree.
Encouragingly, police have put in new measures since the tragedy, which may prevent the same failings recurring.
One of the key questions New Zealanders must be asking in the wake of the tragedy is when will agencies start to share information - albeit in a professional way with appropriate checks and balances to protect privacy and other concerns - to hopefully avert similar situations in the future?
Surely, various agencies must be allowed to discuss and collate such information so any concerns can be more quickly acted upon.
Reports of people falling between the cracks because one agency does not talk to another are frequent.
Inland Revenue's recent move of talking to other government agencies to track tax fraud is reportedly proving successful.
Why not get that sort of co-operation more widely spread?
It has been revealed a reluctance to share information is compromising investigations into family violence, with one expert saying there is a level of anxiety throughout New Zealand about information sharing practices.
Organisations do not feel comfortable sharing material, and instead focus on police information rather than what is in the domain of other organisations.
Quite simply, the silo philosophy of many New Zealand social agencies needs to be removed.
The report from the coroner also reflects something seen before: that signs of family violence are not taken seriously enough in this country.
It is not enough to look at each incident in isolation, without co-operation.
More must be done.
The strength of Ms Webb must be admired.
She is dealing not only with the death of her children and the ongoing effects that must be having on her physically and mentally, but the tragedy is again being played out in the public arena.
Strong women are often left to deal with the aftermath of violence.
Advertising campaigns are unlikely to deter the worst of humanity, but closer co-operation between agencies, a greater awareness within the community of the warning signs and a preparedness to speak up will all help reduce incidents of domestic violence.
Coronial findings are often ignored by authorities, frequently to the detriment of society in general.
That must not be allowed to happen this time.
