Coroner Audrey Jamieson was concerned by the responses of agencies in the lead-up to Ms Warzywoda's 2014 death at the hands of her ex-partner Craig McDermott, saying there were several missed opportunities to intervene.

She made her four recommendations Victoria Police, No To Violence/Men's Referral Service and the Federal Court of Australia, although her findings also concerned the Department of Health and Human Services and Victoria Legal Aid.

Read more: Coroner finds missed opportunities to intervene before woman's murder

Ms Jamieson recommended the Federal Court implement clear policies to ensure security guards report threats.

A security guard at the Federal Court overheard McDermott say he was "going to slice her", but did not tell anyone.

A spokesperson for the court said there were procedures in place that required security staff to report threats to police.

A Victoria Police spokesperson said the organisation would consider the findings and recommendations.

"The issues identified by the State Coroner have also been examined by the Royal Commission into Family Violence and other related inquiries," they said.

"We will continue to work with our service delivery partners to ensure community safety, and address the significant harm perpetrators of these crimes cause to victims."

Ms Jamieson expressed concern about Victoria Police's handling of family violence incidents prior to Ms Warzywoda's murder, and recommended police develop a system for recording phone calls regarding such incidents, update its code of practice on family violence to reflect that withholding children is such an act, and work with No To Violence on a system to ensure all referrals are followed up after police have made contact with a perpetrator.

No To Violence received a referral from police regarding McDermott, but because police had not contacted him, it was never followed up.

Ms Jamieson said it was appropriate the service did not make contact with a perpetrator before police, but suggested a system would stop referrals falling through.

No To Violence welcomed the findings and said it would work with Victoria Police to implement the recommendation.

Chief Executive Officer Jacqui Watt said they would also work with the Federal Court to develop clear guidelines and policies for referral to the Family Advocacy and Support Service.

During her investigation, Ms Jamieson found DHHS' Child Protection arm failed to assist Ms Warzywoda when McDermott withheld their children from her, relied on a school to report a death threat against her, and failed to undertake any safety planning or assessment of the risk to Ms Warzywoda.

But Ms Jamieson did not make any recommendations regarding the department, following a directions hearing in which a representative outlined the changes that had since occurred.

"As noted by the coroner in this case, implementation of the Royal Commission recommendations have significantly improved the way agencies - including Victoria Police and the department - assess the risk and respond to family violence," a department spokesperson told the Bendigo Advertiser.

"Widespread reform work following the Royal Commission into Family Violence has strengthened our response practices to family violence, with greater focus on holding perpetrators to account."

Ms Jamieson was concerned Victoria Legal Aid had required Ms Warzywoda put a caveat on the house she co-owned with McDermott, despite her worries it would anger him.

At the directions hearing, a Legal Aid representative said this requirement was now excluded in cases of family violence.

The subjects of coroner's recommendations have three months to formally respond.

Have you signed up to the Bendigo Advertiser's daily newsletter and breaking news emails? You can register below and make sure you are up to date with everything that's happening in central Victoria.