Ora Holt had been strangled by her delusional, controlling and abusive partner, Greg Floyd, in their Belle Avenue home on Anzac Day 2017.

She fled with her children to her next door neighbours' home, followed by Mr Floyd who shouted that he had been "set up" as the neighbour, Luke Chilcott, urged him to put his gun down.

The neighbours led the couple's children to safety and heard gunshots as they fled.

A major police operation was launched and the pair were later found dead.

Coroner Caitlin English recently said "the circumstances of Ms Holt's death detail a sequence of events that can be described as truly terrifying".

But she said no-one predicted Mr Floyd's behaviour would lead to the tragic outcome, which left their four children orphaned.

In the days leading up to her death, the late mother raised concerns about her husband's behaviour with friends.

Mr Floyd told her he had people watching their home and knew she'd had men around when he wasn't there, while Ms Holt was worried he was monitoring her phone.

Mr Floyd made notes in his diary the day before the murder-suicide.

"Toughest day so far and have realised the enormity of this whole thing ... I believe that whatever [Ms Holt] has told police/DHS it has to be really really bad for there [sic] involvement and not want to speak to me," he wrote.

"Positive friends and family involved so must be massive."

He had attended his doctor 15 days before his death and asked for a test in the belief he may have been drugged.

On April 11, he told a family lawyer Ms Holt was using drugs and believed she had hacked his phone.

He told a social worker five days before the shooting he had no thoughts of harming himself or others, but Ms Holt raised concerns with her friends the same day.

She gave an envelope with cash, notes and a letter to a staff member from the children's school, asking her to put it somewhere safe.

"He is scaring me so much I don't know what to do," the 39-year-old wrote.

Ms Holt was afraid each time he came home.

She told her friend she was being falsely accused of having affairs, and the coroner noted there was nothing to substantiate the various claims made by Mr Floyd.

Ms Holt chatted to a friend the day before her death about speaking to a police officer who was a mutual friend, and agreed to speak to the officer at a party the next day.

"Looking back now, it was as if she was looking for a way to speak to [the officer] without raising any suspicion," her friend later recalled.

Ms Holt's close friends agreed that they would help her when she attended the party.

A plan was organised to take her to the police station or the Centre Against Violence.

The Wangaratta policewoman hosted the party at her house but Ms Holt never made it.

Centre Against Violence chief executive Kerry Burns applauded the actions of Ms Holt's friends.

"The bravery of her friends and neighbours can't be overestimated," she said.

"They didn't walk away from her, they stood with her."

Ms Burns said if Ms Holt had made it to the Centre Against Violence, she would have been assessed as high-risk.

"We would have offered her the full range of services available in terms of intervention orders, access to refuge services and the support she needed for her and her children," she said.

"That doesn't mean the intervention would have saved Ora's life.

"We would have given it our all as would have Victoria Police and others.

"I think there was evidence in the coroner's report that some of the things we're learning about predicting lethality were visible.

"Those include a marked change in thinking in the months before the homicide-suicide, and presenting at mental health places, police, his social worker and his GP.

"His behaviour could be seen as troubled by mental health, it could also be seen as part of family violence."

The coroner's investigation focused on the issue of preventing family violence.

"The evidence in this case suggests that Ms Holt experienced coercive, controlling and manipulating behaviour from Mr Floyd as well as emotional and psychological abuse in the period leading up to her death," Ms English said.

IN OTHER NEWS:

Mr Floyd sought treatment at the Ely Street Clinic and Hume Psychology and Counselling Services in the weeks before his death, and spoke to a family law firm.

Mr Floyd also spoke to a senior constable at the Wangaratta station a day before the murder-suicide, which the officer felt was just to seek general advice, with no concerns he was at risk of harming himself or his family.

None of the services thought Mr Floyd's behaviour raised red flags.

A psychologist noted he had likely been suffering from delusional disorder, but that his delusions were plausible and he presented as normal despite his beliefs.

The coroner noted police and child protective services were not involved in the pair's lives, but said there was evidence Mr Floyd was controlling, jealous, financially abusive, had his wife under surveillance, and used sexual coercion.

He rarely let her go out, had access to guns and feared their relationship was coming to an end.

He had shown similar behaviour to his ex-wife.

"Despite these risks ... no one who knew Mr Floyd or was involved in a professional capacity with him foresaw that his actions were escalating to a point where he was becoming homicidal and suicidal and capable of placing Ms Holt and their children and members of the community in danger," Ms English said.

A review "did not identify any missed opportunities for prevention".

The coroner recommended the Royal Australian College of General Practice review its guidelines for identifying abuse and family violence.