A coroner investigating the domestic violence murder of Queensland woman Doreen Langham has concluded police "failed to take even the most basic steps" to apprehend the man threatening her life.
WARNING: Readers are advised this article contains graphic details readers may find distressing.
Deputy state Coroner Jane Bentley said there was an urgent need to address widespread cultural issues within the Queensland police force and made a number of recommendations for the state government to follow up.
The recommendations included state funding for a specialist victim-centric police station trial designed specifically to respond to domestic violence.
The proposed station would staff police trained in domestic violence, domestic violence workers, social workers and legal advisors.
Magistrate Bentley also recommended state funding for a domestic violence worker to be embedded at the front counter of every police station in the region, and that all police officers be required to view interstate records [of offenders] for every domestic violence matter.
The report suggested the initiative be carried out in the Logan district.
Victim went to lengths to protect herself
Magistrate Bentley handed down her findings at Southport Court on the Gold Coast on Monday after a week-long inquest earlier this year.
Doreen Langham, 49, from Browns Plain, south of Brisbane, died in a unit fire believed to have been ignited by her ex-partner Gary Hely in February 2021.
Both Ms Langham and Hely were killed in the blaze.
Prior to the apparent murder-suicide, the inquest heard Ms Langham had contact with 16 different police officers about Hely, including making complaints and filing for a domestic violence order.
The inquest heard Hely had a "significant" history of domestic violence interstate, and had breached his domestic violence order (DVO) numerous times in the weeks before the fire.
Ms Langham made numerous visits to three police stations and called police to her home several times to tell them her ex-partner had broken into her home, ejaculated on her sheets, made threats to her life and was harassing her via phone.
The inquest also heard Ms Langham had changed her number, car registration, locks, had added security measures to her home, and sought help from a domestic violence service in a bid to protect herself.
Throughout the inquest Magistrate Bentley said Ms Langham had done everything possible to save herself, yet nothing had been enough.
Following Ms Langham's murder, a review into the Queensland Police Service's (QPS) handling of her case was called, with officers who encountered the mother-of-two coming under close scrutiny during the inquest.
Overall, it aimed to determine the specifics of the fatal house fire, Ms Langham and Hely's deaths, the adequacy of the QPS's response to Ms Langham's complaints in relation to Hely, and the response to the triple-0 call on the night of her death.
Magistrate Bentley also determined whether any changes to QPS policies and procedures could reduce the likelihood of similar happenings in the future.
On Monday, Magistrate Bentley concluded Ms Langham died from a combination of the unit fire and an injury to her spleen, which likely occurred during her struggle with Hely after he entered her home.
She concluded Hely lit the fire after dousing Ms Langham and the home with petrol, with the intention of killing them both inside.
Police failed to prevent deaths
Magistrate Bentley told the court the QPS missed countless opportunities for intervention, which would have likely prevented Ms Langham and Hely’s deaths.
She said the responding police officers' response to Ms Langham’s complaints and triple-0 call was inadequate.
"If all complaints had been dealt with properly Hely would likely not have killed Ms Langham and himself."
Magistrate Bentley concluded that none of the failings by police were done so with malice but instead a result of "lack of training and understanding of the complex nature of domestic violence by police, particularly those on the front line".
"The seriousness of Ms Langham’s complaints and risk of lethality should have been noticed and weren’t properly undertaken due to under-training and understaffing," she said.
"I accept there has been an increasing demand for service [since COVID-19], and the police involved have been impacted by the deaths and regret their failings.
"[Hely] continually breached his DVO and committed other serious crimes.
Magistrate Bentley said a holistic approach to the officer’s policing would have revealed Hely’s significant criminal history interstate, and that his domestic violence behaviour was escalating.
In her final comments, Magistrate Bentley expressed her sincere condolences for Ms Langham's family, who were present in the court room to hear her findings.
'He did a monstrous thing'
Speaking outside court, Ms Langham’s daughters Shayne Probert and Tabitha Bleys said they felt "validated" by the findings.
"[The only good to come from this is] Mum would be proud she was helping other women and victims.
"This issue is greater than Logan, so this is just one step."
In a statement the family of Hely described his actions as "horrific and indefensible".
"Gary was not a monster, but he did a monstrous thing," Hely's brother-in-law David Guthrey said.
"He was a man, like many others, who needed support to understand that his behaviour was criminal and that love is not about control but rather equality and respect.
"We don’t know whether such support would have helped him or Doreen but we have to believe that their deaths were preventable.
"We want men like Gary to stop using violence and we want no more women like Doreen to die."
