The Southern District Health Board has also said it is doing its own review after three letters from mental health professionals assured the court Livingstone was no danger.
The latest report from the Family Violence Death Review committee found a system needed to be devised to identify those victims most at risk.
The report also found gaps in the Family Violence Interagency Response System, devised to bring together a range of bodies who had contact with those engaging in or facing domestic abuse. While the system was set up across the country, it didn't have a uniform national approach.
The review found processes to identify high-risk cases foundered in metropolitan areas because of the increased case load. It pointed to other countries that had systems to identify the most dangerous domestic abusers.
The committee also found information sharing between agencies was limited and reviewed some deaths that could perhaps have been stopped if agencies had passed on knowledge they had about a domestic abuser. University of Auckland associate professor Julia Tolmie, who was chairwoman of the committee, said too much onus was placed on the victim and not enough in identifying high-risk offenders.
Some districts used the multi-agency approach to divide up family violence cases to those considered most suitable - basically distributing a heavy workload without getting into the detail.
"The really difficult and dangerous cases were not getting the attention they needed."
She said there were reports Livingstone had made threats to kill, was suicidal and had engaged in stalker-type behaviour.
"There were a number of lethality factors there that should have been setting off red alerts."
The committee report was also critical of the oversight of family violence programmes, saying it had reviewed six deaths in which the perpetrator was taking part in a course that was not measured to quality. It found there was no evidence showing how the programmes matched up with international best practice and "might be considered unsafe". The report also recommended a need to improve police enforcement of protection orders.
Family violence support group Shine director Jill Proudfoot said there needed to be a stronger national approach. "At the moment it's an absolute lottery what will happen when [victims] call 111 about protection orders."
A police spokeswoman said there was national oversight of how police were dealing with domestic violence cases and that family violence cases were reviewed to make sure they were dealt with properly.
Police Minister Judith Collins said she had sought advice on using GPS to better protect those who had taken out protection orders.
She said protection order breaches were now punished more severely and further changes were planned to make court processes and domestic violence courses more effective.
nzherald.co.nz
Read more on David Fisher's investigation into the Dunedin deaths here: tinyurl.com/fisherstories.
