A series of critical “errors and omissions” made by police, firearms registry staff and a family court lawyer in New South Wales allowed a man with a decades-long history of domestic violence to murder his two teenage children in 2018.
The state coroner, Teresa O’Sullivan, on Wednesday repeatedly paused to compose herself as she read out the findings of a months-long inquest into the deaths of Jack and Jennifer Edwards, who were aged 15 and 13 when killed in 2018.
The two teenagers were shot dead by their estranged father, John Edwards, a 68-year-old retired financial planner and former member of the Australian defence force. Police at the time described the shootings, on the afternoon of 5 July, as “premeditated and planned”.
The bodies of the children were found beneath a desk in Jack’s bedroom – where they had hidden after Edwards stalked Jennifer on her way home from school.
Later that night, Edwards killed himself. Their mother and his estranged wife, Olga, slept in her son’s bed after his death before she killed herself in December that year.
An emotional O’Sullivan on Wednesday described the deaths as a “preventable” crime, pointing to a litany of errors made by police, the state’s firearms registry and the family court before the shootings, which she said were “a stark reminder of the broader systemic problems that face too many women and children every day”.
“It is difficult to imagine the pain that Olga felt when she returned home from work on 5 July 2018 to find police at her home and [realise] her two children who she loved dearly had been killed,” O’Sullivan said.
“This moment was the crystallisation of the fear she had harboured as the victim of domestic abuse [and] as the mother of two children [who were] victims of domestic violence.”
O’Sullivan’s 270-page report included 24 recommendations after she heard from more than 30 witnesses during the inquest. The recommendations included a call for police in the state to bolster mandatory domestic violence training for officers, training for firearm registry staff to recognise risks of domestic violence, and better information sharing between the gun registry, police and the family court.
Investigations after the shootings revealed Edwards had what the counsel assisting the inquest, Kate Richardson SC, called a “propensity for domestic violence and a history of psychological and physical assaults stretching back to the early 1990s”.
But despite significant evidence that the family had disclosed Edwards’ violence to police and officials in the family court system, O’Sullivan identified a litany of serious errors made by court officials, police and firearms registry staff.
Describing the shooting as “a tragedy” was not sufficient, she said.
“To describe this as a tragedy is to import a sense of inevitably, that nothing could have been done to change the outcome,” she said. “Instead, the evidence before this court plainly reveals that the deaths of Jack and Jennifer Edwards were preventable.”
The inquest heard that when their marriage broke down in March 2016 after years of abuse, Olga had made two reports to police about Edwards’ conduct, including his violence towards Jack.
But the details of allegations were misrecorded by a senior constable who had never opened the police handbook on family violence, the coroner found. Olga was recorded as a victim and Edwards the “person named” while the incident was incorrectly classified as “no offence detected”.
In a second instance, when Olga reported that Edwards had shown up to her yoga class in early 2017, the officer recorded the incident incorrectly, meaning it did not show up on Edwards’ police record.
These “errors and omissions” meant that when Edwards later applied for a firearms licence the events did not show up on his file, the coroner said. NSW police, she said, had “failed to undertake reasonable inquires” in the first instance and failed to investigate the second incident adequately.
Key to the inquest had been understanding how Edwards gained a firearms permit despite a long history of domestic violence allegations made against him by numerous former partners and other children.
In her findings, O’Sullivan was scathing about the role of the firearms registry, saying staff lacked formal training and failed to recognise Edwards’ long pattern of domestic violence when granting him the licence that allowed him to buy the deadly weapons he used to kill his children.
She said information relied on by staff at the registry was “unduly narrow” because of a mistaken belief that a licence should only be refused if there was a “mandatory” reason to do. There was a “complete failure to appreciate the pattern of domestic violence going back 24 years”.
NSW police said on Wednesday the firearms registry had undergone significant changes since the shootings – something O’Sullivan noted in her findings.
“Since 2018, the NSW Firearms Registry has undergone an extensive restructure which has resulted in enhanced compliance and better identification of breaches of the legislation,” a police spokesperson said in a statement.
“Significant changes to the firearms registry processes and systems have led to greater scrutiny and assessment of licence application and renewals which are now oversighted by senior adjudicators.”
The assessments mean a licence can be suspended or revoked on a number of grounds, including involvement in a domestic violence-related incident, mental health-related events, involvement in criminal activity, association with criminal groups or being in the public interest.
The spokesperson said police would “review the [inquest] findings and consider all recommendations that are directed to police”.
O’Sullivan also referred the independent children’s lawyer, Debbie Morton – who was tasked to represent Jack and Jennifer’s best interests in the family court – to the Office of the Legal Services Commissioner to “investigate whether any disciplinary action ought to be taken”.
The coroner found Morton had not properly considered objective evidence, or the statements by Olga Edwards and the children, before addressing the family court in relation to Edwards’ risk.
The inquest was told that the Edwards children had spoken of their father’s violence to several health professionals and experts involved in the court proceedings. But the independent children’s lawyer told the inquest the teenagers hadn’t raised those concerns with her before she pushed for weekly access visits.
Morton defended not telling the family court months later that Jennifer wanted an explicit order forbidding her father from contacting her, saying judges and magistrates had previously told her not to disclose a child’s actual wish in court.
O’Sullivan was critical of the lawyer, saying she had “failed to inform the court of Jack and Jennifer’s views about contact with their father” and “did not properly consider the available objective evidence”.
Olga was the seventh woman with whom Edwards had children – he had 10 children in total – and police records showed that allegations of violence and stalking against him had been made in relation to four of his previous partners, one of his adult daughters and, as recently as 2016, Jack and Jennifer.
But the inquest heard NSW police had not charged Edwards with any offence since 1998 and had approved his gun licence in 2017.