A Queensland coroner has said police failed to see the "extreme danger" Hannah Clarke and her three young children faced.
New Zealand-born Rowan Baxter was called a "master of manipulation" who planned to kill his family.
The warning signs were there. When police had asked how he was acting, Hannah Clarke said earlier: "Oh just a psycho, that he's taking her."
A coroner has ruled police didn't do enough to help Clarke.
In earlier footage of a conversation between Clarke and a police officer, the officer told the mum they cannot give her her child back.
"Unfortunately, because he was a biological father of the child, we can't just go and seize the child and give it back to you," the officer said.
Clarke responded to the police officer and said: "This is so messed up."
Coroner Jane Bently found "there was a failure by all agencies to recognise her extreme risk".
But despite Rowan Baxter breaching a domestic violence order and being released by police, no one could predict the murderous plans he carried out just 10 days later.
He ambushed Clarke on the school run and set fire to her and their three young children.
"He was not mentally ill. He was the master of manipulation," Bently said.
New Zealand-born Baxter planned his attack by buying a petrol can in the days prior when he realised he could no longer control his wife.
"I think he underestimated how much a mother would fight, and how strong a mother is. He didn't love the children like she did. He had no idea what a mother will do," Clarke's mother Sue said.
One thing she did was tell the police as she lay dying exactly what Baxter had done.
Until then, no one had any idea that Clarke had been in extreme danger.
Bently said nothing was picked up earlier because Baxter did not have any previous criminal record.
"Due to the fact that Baxter had not been physically violent, he had no relevant criminal history."
The coroner concluded that overall, Clarke was "dealt with appropriately by the police officers".
Four recommendations were made. Among them was more specialised domestic violence training for police.
Clarke's parents Sue and Lloyd said education on the issue would help a lot.
"With the education, no one will fail to see that risk again," Sue said.
"Yeah it's the education that let her down," added Lloyd.
Her parents have continued to advocate for change, founding Small steps 4 Hannah.
When asked if they thought Clarke, would be proud, Sue "I'd like to hope so".
Where to find help and support:
- Shine (domestic violence) - 0508 744 633
- Women's Refuge - 0800 733 843 (0800 REFUGE)
- Need to Talk? - Call or text 1737
- What's Up - 0800 WHATS UP (0800 942 8787)
- Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
- Youthline - 0800 376 633, text 234, email talk@youthline.co.nz or online chat
- Samaritans - 0800 726 666
- Depression Helpline - 0800 111 757
- Suicide Crisis Helpline - 0508 828 865 (0508 TAUTOKO)
- Shakti Community Council - 0800 742 584
