Several government departments made "significant errors" before Henry David Shepherdson murdered his nine-month-old daughter Kobi Anastasia Isobel on April 21, 2021, acting Deputy State Coroner Ian White said.
Shepherdson killed Kobi at the Barossa Dam's Whispering Wall in Williamstown, northeast of Adelaide, on the day a court order was varied to allow him contact with his daughter.
In findings delivered on Wednesday, Judge White made recommendations to the South Australian government aimed at protecting domestic violence victims.
"This was a difficult, harrowing examination … of a mother and child being subject to domestic violence and coercion by a manipulative, self-absorbed and dangerous man that resulted in Kobi's murder," he wrote.
"Kobi's death, an upsetting and terrible shortening of her life, can and did evoke strong emotions and reactions ... it was a murder-suicide in public."
The infant and her father died hours after a magistrates court granted a variation to a no-contact order to allow Shepherdson to care for Kobi while her mother was at an appointment.
In December 2020, Shepherdson had been charged with false imprisonment and threatening to kill and a no-contact order was imposed to stop him contacting Kobi and her mother, who cannot be named.
But while he was in prison, he breached that order by calling her 149 times, exerting coercive control over her and manipulating her into dropping the charges.
The calls were not known to police, investigators, prosecutors or to the magistrates court.
Judge White said he was extremely disappointed by police submissions that Kobi's mother "could have simply refused to answer calls from him".
"I challenged these submissions … as being totally inappropriate considering what was heard in these samples of calls," he said.
The ultimate effect of Shepherdson's behaviour was that he regained his legal right to have contact with Kobi on the same day "he murdered her so brutally," Judge White said.
Prison operator Serco, SA police and the Correctional Services Department each made significant errors that "cannot be ignored", he said.
He made extensive recommendations to Premier Peter Malinauskas, Attorney-General Kyam Maher and Police Commissioner Grant Stevens.
They included adopting recommendations already made by Domestic, Family and Sexual Violence royal commissioner Natasha Stott-Despoja.
Comment has been sought from the SA government and Mr Stevens.
Judge White also recommended a review of the prisoner phone service to prevent protected people being contacted, and the amendment of non-contact orders to more easily identify previous convictions for breaching orders.
Safety issues at Whispering Wall had already been substantially addressed, Judge White said.
There had been a deliberate choice to examine in detail the relationship between Shepherdson and Kobi's mother "to give a clear insight of the insidious problem of domestic violence and the often-silent suffering of domestic violence victims", Judge White said.
He acknowledged the distress this may have caused the family, and said he sincerely hoped his recommendations would lead to substantial assistance towards the protection of domestic violence victims.
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