How can a system designed to keep people safe follow all the right procedures and end with two women murdered?
That's the question confronting West Australians in the wake of Ariel Bombara's devastating account of her experiences with police before her father took the lives of Jennifer and Gretl Petelczyc.
"My mother and I made it clear that our lives were at risk – we were repeatedly ignored, repeatedly failed," the 27-year-old said.
They were words that changed the course of the week following the tragedy.
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The next day, just hours after announcing a review into how officers handled Ariel's reports, Commissioner Col Blanch insisted all processes were followed.
"On this particular occasion, when Ariel and her mother attended Mirrabooka police station the officer there took the family violence incident report," he told ABC Radio Perth.
"That immediately ... automatically triggers a number of functions.
"It does a risk assessment based on what was known at the time, it sends information to the family and domestic violence response team so they can triage that information.
"That was done. There was a triage meeting. It was referred to a third party through the Department of Communities for action. All of those things did happen."
It was a similar story from the relevant government department.
"Communities can confirm that correct protocol was followed by the non-government service provider," a spokesperson said on Wednesday.
And even still, despite those processes upheld — Mark Bombara was allowed to keep his 13 firearms and did not get the help he needed.
His daughter and estranged wife were told by police they didn't meet the threshold for a temporary restraining order, and Bombara murdered Jennifer and Gretl inside their home when he couldn't find his wife.
That even the most catastrophic outcome could not be prevented by the well-intentioned people using those processes brought into sharp focus fundamental flaws in the systems we rely on to keep women safe.
"That's an example of how we need to continue to make sure that our laws are contemporary, and meet the needs of the community," was the premier's answer on Thursday.
"And that's the reason why ... we're bringing in new family domestic violence laws.
"That's the reason why we continue to make sure that we look at the processes that police operate under to ensure that they're supported by laws, which better support them in the decisions they make."
And while police aren't the answer to these problems, for many victim-survivors they are the first place they seek help, probably when a situation has reached crisis point.
One call every six minutes
According to the commissioner, they are confronted with around 60,000 family and domestic violence reports a year – about one every six minutes.
Mixed in with all the other work of police already stretched thin, even well-intentioned officers might not be able to give each one the attention they need.
"Responses of police vary from one station to another and police don't always take claims made by victim-survivors seriously enough, especially in the absence of physical violence and damage to property," said the Centre for Women's Safety and Wellbeing CEO, Alison Evans.
About three-quarters of those reports to police end up being assessed, triaged and responded to by family and domestic violence response teams, made up of government and domestic violence services.
The next step from there – after a triage and potentially a risk assessment – might be a support service which cannot keep up with demand, or a place in a refuge which is overflowing.
The process might be followed in the sense that a safety plan is completed, but the woman is yet to receive the help they need.
"Those providers have no capacity or authority to influence or work with the perpetrator, and that's what needs to happen, only police can do that," the CEO of women's health provider Luma, Felicite Black said.
That's not to say this is what necessarily happened in the Bombara case – that is still subject to both that internal police investigation and the broader coronial probe.
But those probes, and the changes advocates hope they inspire, cannot end with tinkering around the edges.
A new Firearms Act, which has received a lot of attention over the last week, might be part of the solution.
So too might be changes to restraining order laws to lower the threshold for them to be issued, as the police commissioner has referenced.
But each change to the law is just one part of what's needed.
"We can pass as many laws as we like, but if we can't administer them well then that's not going to get to the root of the problem," Liberal MP Neil Thomson said upon arriving at parliament to debate those laws on Thursday.
Broader reforms in the FDV space have been promised and take on a critical importance after the events of the last week.
As part of that process, the government has promised to set up a lived experience advisory group to hear the voices of victim survivors.
Even without a formal group though, their message is clear – listen to survivors, and take rapid action to learn from the tragedies they've watched from far too close.
History repeating
Take what Jacqueline Darley shared this week.
In December 2022, she told police she was worried about her sister, Lynn Cannon, because her estranged husband had been threatening to kill Ms Cannon.
It took officers more than an hour to attend, after the priority of the job was downgraded, and when they did, Ms Cannon had already been fatally wounded.
"They're still not listening, they're still not taking it seriously," Ms Darley said.
"When you're being told constantly we are taking this seriously, and then you hear that more lives have been lost needlessly when there was time to save them, it's frustrating."
And similarly from Ariel, who delivered this message through her grief on Tuesday.
"Men will kill regardless of what weapon they use," she said.
"If they want to, they will find a way.
"There needs to be a massive systemic change made to protect women to ensure that this never happens again.
"I'm not a lawyer or a politician or a policeman. That's their job, is to solve this problem.
"It shouldn't fall on the women who are survivors of domestic abuse to have to solve the problem.
"It's on our governments. That's what you're employed to do."
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