A coroner has found inaction by Tasmania Police and "unfortunate" legal advice left a woman who was killed by her estranged husband unprotected.
In handing down his findings into the 2015 death of Olga Baraquio Neubert, Coroner Simon Cooper said Mrs Neubert died as the result of a contact gunshot wound to the head inflicted by her husband Klaus Dieter Neubert.
Mrs Neubert, 37, was shot by her husband in her vehicle on a busy greater Hobart street on May 14, 2015.
She was rushed to hospital but did not survive her injuries.
Neubert in 2017 was found guilty of murder and sentenced to 25 years' jail.
Mr Cooper said a year earlier Mrs Neubert had told her husband she was leaving their marriage.
A number of confrontational episodes between the pair followed including a September 2014 incident in the USA which resulted in a 14 day Abuse Prevention Order, which is the same as a family violence or domestic restraint order in Tasmania, being made by a local judge. It was not renewed.
Once back in Tasmania, Mrs Neubert's husband commenced a search for her which included reporting her as a missing person to police.
Police contacted Mrs Neubert to ensure her safety, but did not provide her location to her husband.
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On April 21, 2015, about a month before her death, Mrs Neubert sought assistance from solicitors who advised her to attend a police station if she wanted immediate protection.
She then attended Bellerive Police Station and spoke to a police officer, who has since left Tasmania Police, for about 15 minutes but was unable to persuade the officer there were grounds to make a police family violence order.
"The upshot of Mrs Neubert's consultation with her solicitors and subsequent attendance upon Tasmania Police is that when she left the Bellerive Police Station no order of any type protecting her from her estranged husband was in place," Mr Cooper said.
"In assessing whether the [police] officer may have been justified in his approach, I note he did not even identify who Mrs Neubert was.
"If he had, he would have been able to access information held by Tasmania Police relating to her and her husband, relevantly, relating to him having reported her as a missing person and which entry included information about the protective order made in the USA."
Mr Cooper said there was no clear reason why the officer did not make an entry into the police family violence management system.
"I accept that Tasmania Police's inaction, and the legal advice she received, did not cause Mrs Neubert's death. However, I consider it necessary to comment that both led to a situation where she was unprotected by a system designed to protect people such as Mrs Neubert," he said.
Mr Cooper noted Tasmania Police had conducted a review of Mrs Neubert's interaction with police which found the officer had not breached any departmental policies.
He rejected the reviewer's assertion police would expect people wanting help to be ready to provide more evidence.
"Even without the benefit of hindsight, it should have been obvious that she was particularly vulnerable," he said.
"Police actually had extra evidence but the officer involved chose not to look for it."
Tasmania Police Deputy Commissioner Scott Tilyard said the organisation's internal review of its interaction with Mrs Neubert identified a system gap which did not capture reporting of events which did not fall within the legislative definition of family violence.
"This gap was rectified with new processes and procedures implemented to ensure that any information provided to police, concerning people in an intimate relationship, is captured in one system - the Family Violence Management System," Deputy Commissioner Tilyard said.
"This ensures information is available to Safe at Home service providers to ensure a collaborative response."
Mr Cooper said the advice given by solicitors to Mrs Neubert was "unfortunate" because they were quite aware of the history between Mr and Mrs Neubert and a magistrate would not have needed to be convinced based on this evidence to make an interim protection order on an urgent basis.
"I observe that had an order under the Family Violence Act 2004 been made protecting Mrs Neubert from her husband it would certainly have contained an order requiring him to surrender his firearms," he said.