Coroner releases report on Livingstone filicides-suicide

Tue 23 Jun 2015

Chief Coroner Judge Deborah Marshall has released her report into the Livingstone double murder-suicide. The inquest into the deaths of Bradley, ...

Chief Coroner Judge Deborah Marshall has released her report into the Livingstone double murder-suicide.

The inquest into the deaths of Bradley, Ellen and Edward Livingstone was held in April 2015. Bradley, 9, and Ellen, 6, were shot by their father, Edward Livingstone, in Dunedin on 15 January 2014. The summary of recommendations is publicly available.

In her report, the Coroner said "valuable lessons" for the future could be taken from the tragic deaths. These would enable agencies to better assess risk and take specific actions to reduce it. She commented on the need for health professionals to take care when providing letters to a court. She recommended that Police:

  • Institute family violence training for all frontline officers and family violence specialists
  • Review how family violence is recorded to ensure there is a central information repository that Police can access
  • Audit the new Adult Sexual Assault regime implemented in the Southern District and review whether the changes should be implemented nationally
  • Institute regular audits of Family Violence Interagency Response System (FVIARS) processes

Lawyer Ann Stevens, who represented the children's mother Katharine Webb, was interviewed about the findings on Radio New Zealand. She said Ms Webb did not accept the Coroner's suggestion that "best practice" by the agencies involved might not have altered the tragic outcome.

"That's probably the most important finding to Katharine and and myself, and the most distressing finding, because that implies there's an inevitability about this that we just can't accept. Inevitability comes with tides and with the sun rising but it doesn't come with human behaviour, in our view. As the report makes clear ... these were choices that Mr Livingstone made, choices to murder his children and those choices would be different, in our view, given different factors."

Other responses and further information are available in the media coverage below.

Background information

Background information, including media coverage from January 2014 to January 2015 and links to relevant research, is available in the previous Clearinghouse news story on the filicides.


In December 2016, the Otago Daily times (ODT) was provided with a summary of the NZ Police report on the employment investigations into the Police officers who dealt with Edward Livingstone. The ODT writes that the report, The Livingstone Family Violence Investigation Report: Adequacy of Dunedin police service delivery, written by then Detective Inspector Virginia Le Bas, now national manager, organised crime, states that at the time of the tragedy:

  • "One person within Dunedin police was assigned 200 to 300 family violence files without administrative support.
  • National policy on intimate partner rape was lacking.
  • Greater leadership in cases of adult sexual assault and family violence in Dunedin was required.
  • Officers involved in the case breached the police code of conduct." 
The summary report was released to the ODT after an 18 month process involving the Official Information Act and then the Ombudsman.

Chris Foot, a neighbour who confronted Edward Livingstone in an attempt to prevent him from harming his children, received a New Zealand Bravery Decoration, an award recognising an act of exceptional bravery in a dangerous situation.

Other updates are available in the media coverage below.


Prison worker's grievance fails, Otago Daily Times, 13.07.2017

Complicated love life of Mr X: Prison guard loses his job for sharing intimate details of workmate, Stuff, 12.07.2017

Deficient policing detailed, Otago Daily Times, 26.12.2016 

Dunedin man Chris Foot thought he would be shot by child killer Edward Livingstone, Stuff, 01.08.2016

Police maintain silence on disciplinary actions, Otago Daily Times, 14.07.2015

Child safety investigations should be mandatory, Press Release: Green Party, Scoop, 24.06.2015

Removing silo mentality, Opinion, Otago Daily Times, 24.06.2015

Mother of dead children can't accept findings, Radio NZ, 23.06.2015

Livingstone case: Coroners report shows red flags, Radio NZ, 23.06.2015

Women's Refuge welcomes change following murder, TV3, 23.06.2015

Livingstone murders: Red flags in Kiwi St tragedy, NZ Herald, 23.06.2015

Support for greater transparency between agencies, NZ Herald, 23.06.2015

Livingstone murders: Police accept Coroner's findings, NZ Herald, 23.06.2015

Editorial: Failure to catch a high-risk monster, Timaru Herald, 23.06.2015

Editorial: Determined killers hard to prevent, The Press, 23.06.2015

Response to findings in Livingstone case, Press release: NZ Police, 22.06.2015

Edward Livingstone: Failures mean high risk missed, Stuff, 22.06.2015

Police: Changes made after Livingstone, Radio NZ, 22.06.2015

Lost opportunities before Livingstone killings – coroner, TV3, 22.06.2015

Livingstone murders: Coroner's report released, NZ Herald, 22.06.2015

Letting down the victims of violence, Marlborough Express, 06.05.2015

The danger signs of family violence, SunLive, 02.05.2015

Police mum on action over Livingstone case, Otago Daily Times, 01.05.2015

Police take action over 'significant' failings, Otago Daily Times, 01.05.2015

Police act against Otago officers, Radio NZ, 28.04.2015

'Real gap' in protection order system, Radio NZ, 28.04.2015

Cops take action in Livingstone case, NZ Herald, 27.04.2015

Listen to coroners, dean urges, Otago Daily Times, 25.04.2015

'Heroic' attempt to save children, Stuff, 25.05.2015

Inquest: Police 'fell short' in duty of care, Otago Daily Times, 24.04.2015

Livingstone inquest: Police failed mother and children, NZ Herald, 24.04.2015

Edward Livingstone's descent into 'primal, wounded hateful self', Stuff, 24.04.2015 

Psychotherapist naive and wrong, inquest told, Radio NZ, 24.04.2015

Police commander says Livingstone case will cause great change, Radio NZ, 24.04.2015

Livingstone's therapist wrong and naive to write letter, Radio NZ, 24.04.2015

Last day before murders revealed, NZ Herald, 24.04.2015

Deaths force changes to policing, NZ Herald, 23.04.2015

Police didn't explore neighbours' concerns, Radio NZ, 23.04.2015

Killer father deliberated over decision, NZ Herald, 23.04.2015

Livingstone inquest: Former flatmate feels 'manipulated', Otago Daily Times, 23.04.015

Livingstone Inquest: Suicide note presented, NewstalkZB, 23.04.2015 

Supervisor not surprised by killings, Radio NZ, 23.04.2015

Livingstone: 'No malice' in illegal contact with wife, 3 News, 23.04.2015

Edward Livingstone inquest: Killer dad left chilling note, The Press, 22.04.2015

Livingstone inquest: Police handling queried, NZ Herald, 22.04.2015

Police admit major failings in Livingstone shooting, Radio NZ, 22.04.2015

Inquest fires calls for tougher protection order regime, Radio NZ, 22.04.2015

Livingstone inquest: 'I saw a rifle with Edward behind it', NZ Herald, 22.04.2015

Livingstone deceived psychiatrist, Radio NZ, 22.04.2015

Edward Livingstone's threat may have gone unreported - witness, 3 News, 22.04.2015

Livingstone inquest: Killer father deceived psychiatrist, NZ Herald, 21.04.2015

Livingstone inquest: Psychiatrist deceived, Otago Daily Times, 21.04.2015

Livingstone told his neighbour he wanted to kill his children, Radio NZ, 21.04.2015

'I think he's killed the kids,' screamed Dunedin mum as she fled armed ex, Stuff, 21.04.2015

Chilling facts from the Livingstone inquest, Radio NZ, 21.04.215

Answers sought over why father killed children, Radio NZ, 21.04.2015

Livingstone inquest reveals rape, threats, Radio NZ, 21.04.2015

Livingstone had told of plot to kill children – neighbour, 3 News, 21.04.2015

Inquest into murder of Dunedin children, Otago Daily Times, 20.04.2015

Livingstone inquest: Killer father deceived psychiatrist, NZ Herald, 20.04.2015

Coroner's probe: Why did Dunedin father Edward Livingstone kill his children, Southland Times, 20.04.2015

Edward Livingstone inquest: Double murder-suicide, The Press, 20.04.2015

Lessons for us in tragic deaths, Wanganui Chronicle, 06.05.2015

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Image: Marcus Obal