Maryam Hamka, 36, was killed by her partner Toby Loughnane in April 2021 at his Brighton apartment, in Melbourne's southeast.
Weeks earlier, on March 6, police responded to reports of a separate incident in which Loughnane chased Ms Hamka while armed with a knife to her mother's home.
Victoria Police's Family Violence Investigation Unit triaged the incident as medium risk in line with its guidelines.
In findings released on Tuesday, State Coroner Liberty Sanger said Loughnane's long history of family violence should have raised greater concern and warranted specialist oversight.
"This incident should have been classified as high risk," she said.
When police arrived, Ms Hamka had already left the scene and denied the incident took place when they contacted her.
Her sister, however, told police the incident did take place, telling officers Loughnane had also "bashed her really bad previously".
A police report noted the parties had no previous family violence reports despite Loughnane's history of family violence.
On April 11, Loughnane killed Ms Hamka and later buried her body in a shallow grave at Cape Schanck, on the Mornington Peninsula.
A jury found him guilty of murder and, in February 2025, he was sentenced to 28 years' imprisonment with 20 years non-parole.
Judge Sanger did not suggest a different rating would have prevented Ms Hamka's death or that it was wrong under the relevant policy, but said it may have overlooked the gravity of Loughnane's violence.
"Even if the risk assessment tool did not assess this as high risk, in my view, this does not obviate the need for members to use professional judgment," the coroner wrote.
Loughnane had been recorded by Victoria Police as a family violence perpetrator on 21 occasions.
He had been jailed for violent offending, breached court orders and been managed under high-risk police monitoring in relation to other women.
Judge Sanger recommended the state government fund an independent evaluation of Victoria Police's risk models and Family Violence Investigation Units.
She also called on the Department of Families, Fairness and Housing to provide ongoing funding for long-term perpetrator interventions.
1800 RESPECT (1800 737 732)
Lifeline 13 11 14
Men's Referral Service 1300 766 491
24°C