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Peter Lee told his wife he would kill her and her family and despite her pleas for help, early on the morning of Sept. 4, 2007, he did.

A coroner's inquest into those deaths concluded yesterday that British Columbia needs a province-wide domestic violence unit and consistent training in threat assessment across the criminal-justice system to prevent another tragedy on that scale.

After a 12-day hearing that spanned 19 months, the five-member jury issued 14 province-wide recommendations that would change the way police investigate and how the courts prosecute the estimated 10,000 domestic-violence complaints made each year in B.C.

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The recommendations include:

risk assessments be conducted before someone is released on bail;

stricter bail conditions, particularly for people who cannot provide a fixed address;

education and advertising campaigns against domestic violence; and

advocacy services for both victims and abusers.

The changes proposed are unusually broad but reflect the high profile of the case. Coroner Jeff Dolan, speaking to reporters at the end of the hearing, predicted the government would comply with the jury's recommendations.

"The recommendations aren't enforceable. However, they do become part of the public record." He said he is confident there will be a "high compliance rate."

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B.C. Solicitor-General Kash Heed made no specific promises yesterday but said he will deliver "a comprehensive response to domestic violence in British Columbia" in the wake of these recommendations.

He is expected to announce new initiatives next month based on both the coroner's inquest and the changes recommended by the Representative for Children and Youth, Mary Ellen Turpel-Lafond, in her report earlier this fall on the Peter Lee killings.

The inquest heard a litany of missed opportunities to intervene with the family since the first complaint to police about domestic violence in 2003.

But the risks escalated sharply in the summer of 2007 when Sunny Park told Mr. Lee she wanted a divorce. Mr. Lee was charged after he allegedly tried to kill her in response, and was released on bail.

Shortly after 3 a.m. on Sept. 4, 2007, a chilling 911 call was taken by a Victoria police dispatcher. Before the line was disconnected, it was clear something terrible was happening at 310 King George Terrace in Oak Bay.

Mr. Lee broke into the family home and stabbed to death his six-year-old son Christian Lee, Ms. Park and her mother, Kum Lea Chun, and her father, Moon Kyu Park. He then killed himself with the same military-style knife.

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The jury concluded that all five members of the family bled to death from multiple stab wounds within minutes of the 911 call. By the time police arrived, there was no one to save.

The inquest also heard that there were warning signs but no comprehensive system in place to put the information together and assess the escalating danger that an abusive, jealous husband posed after losing his home, his job and his family.

"It's loud and clear that B.C. lacks an integrated, co-ordinated, province-wide response to domestic violence," said Ms. Turpel-Lafond. She said the testimony at the inquest from a senior criminal justice official that B.C. can't afford a better system was disturbing.

"Four innocent people were murdered including a child," she said. "The idea that we can't afford to do better doesn't ring true."

Diane Turner, lawyer for the Ending Violence Association, said the inquest exposed many gaps in service that continue to fail families living with domestic violence.

"I would hope the deaths of five people in this fashion would motivate the government to do something about this. This shook the community, it shook the country and I hope it shakes the government."

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