Queensland police failed to identify or act on "numerous risk factors" before Brock Wall murdered his ex-girlfriend and their unborn child, a coroner has found.
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Wall also told DVConnect Mensline he was going to kill Fabiana Palhares but the call taker did not record this information or notify anyone of the threat, Deputy State Coroner Jane Bentley says in findings released on Wednesday.
The Gold Coast man was sentenced in 2018 to two life terms in prison with a 20-year non-parole period after pleading guilty.
He attacked Ms Palhares, 34, who was about 10 weeks' pregnant, with a tomahawk and jumped on her stomach as she screamed for help on a triple-zero call in February, 2015.
Ms Bentley said it was impossible to determine whether the tragedy would have been avoided if police and DVConnet Mensline had acted appropriately.
But following initiatives and improvements by both agencies since Ms Palhares' death, the coroner said an inquest wasn't required as she couldn't recommend anything else to prevent similar deaths in future.
Wall, who had a long history of violence against previous partners and his mother, was served with a domestic violence protection order barring him from Ms Palhares' home two hours before he killed her.
Between December 29, 2014 and her death on February 2, 1015, Wall and Ms Palhares had seven contacts with police.
But Ms Bentley said recurring issues included a failure to appropriately document, identify, respond to and investigate reports of domestic and family violence.
"A total of 26 lethality risk factors were present for Ms Palhares and most of these risks were known to responding officers or were reported to police previously," the coroner found.
"It appears that police responded to each report of DFV in isolation, rather than as an escalating pattern of behaviour."
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