Failings in handling of Buckley case were 'systemic'
Questions will be asked of all the agencies involved in this case but most will be directed at Gwent Police.
It is not the first time force failings have been identified, and it is not the first time people have died.
Bobbie Stokoe, Joanna Michael, Caroline Parry are just some of the victims who died as a result of violent partners. In each case Gwent Police shortcomings were identified in a series of reports.
Now the names of Kim Buckley, her daughter Kayleigh, and Kayleigh's six-month-old baby Kimberley will be added to that list. They were killed in September 2012 in a house fire set by Kayleigh's violent boyfriend Carl Mills, who was originally from Bolton.
A serious case review was set up to identify shortcomings and learn lessons for the future.
In regards to Gwent Police is found multiple serious failings. The most serious is that they didn't have a complete picture about a man with a history of violence. Information, which had it been known, could have protected the family from him.
Professor Martin Innes, director of Cardiff University's Police Science Institute, says the failings were systemic.
As early as December 2010, the force knew that Mills posed a "significant risk" and they told Kim Buckley.
The report found four other UK police forces had information about previous convictions and intelligence on Carl Mills but Gwent Police didn't obtain it. Their arrangements for accessing information from other police forces didn't comply with national recommendations made in the 2004 Bichard Report.
There were at least 45 incidents of violence committed by Mills in his home town of Bolton including offences against his mother by setting fire to her bed thinking she was in it, threatening her with knives and physical violence.
The serious case review says the volume of information from checks led to difficulties in its administration and a backlog so a decision was taken in the force to 'switch off' and not progress the data which then became "irretrievable."
Gwent Police knew their information on Carl Mills's history was incomplete, but they didn't tell that to other agencies such as social services who assumed they had a complete record about him. They didn't.
What is now clear is that Carl Mills was a dangerous, controlling man. But it's too late for the Buckley family.
The report says had more been known about his history then action would have been taken to protect the family and it's likely they would still be alive.