Oregon lacks a coordinated approach to combat domestic violence, which has killed more than 500 Oregonians in an 11-year period, an Oregon Secretary of State report released Tuesday found.

The advisory report said Oregon has a fragmented system that fails victims when they are in a crisis. They may need to navigate the courts system to file restraining orders against their former partners, find employment and affordable housing and often obtain counseling. In Oregon, more than a third of adults experience domestic violence within their lifetimes, which can include physical, sexual or emotional abuse, including threats.

Due to the complexity of the cases, no singular local or state agency is involved: The courts, police agencies, housing and social services agencies all play a role, along with nonprofit organizations that help victims. As a result, the Secretary of State’s report is not an audit that would focus on one agency that needs to improve.

“Domestic violence is pervasive, immensely harmful, and often fatal,” Audits Director Kip Memmott said in a statement. “This is an area where state government can do more to help. As auditors, we are uniquely positioned to provide state leaders with information and offer potential solutions on critical issues of public health and safety.”

Problems persist throughout the system that prevent victims from accessing the services and help they need, the report found.

Bureaucratic red tape forces agencies to spend time filing monthly or quarterly reports and other paperwork instead of working with victims, the report said.

Funding is often limited. For example, a federal program that provides temporary help for domestic violence victims only offers up to $1,200 for a 90-day period — an inadequate amount that hasn’t changed since 1997.

In that vein, affordable housing is limited, giving victims few choices, the report said.

Rural social service agencies often have fewer resources to help victims find housing, child care and financial aid than urban areas. For example, four rural counties in northeastern Oregon — Gillam, Sherman, Wasco and Wheeler — have just one domestic violence services nonprofit that operates from one location, the report said. And that organization faced upheaval after its former director was arrested for embezzling funds, the report said.

The court system also fails victims, the report said. If victims want to file an order to prevent their abusers from contacting them, they must navigate a complex court system, regardless of whether they can afford an attorney. Legal aid attorneys can help victims who cannot afford a lawyer, but those organizations reported they can only serve about 15% of the victims seeking aid, the report said.

Even when victims file a protective order, they’re not always safe. Advocates told state auditors that police don’t always arrest abusers who violate protective orders and contact their former partners, the report said. Sometimes, officers will simply take a report over the phone if they don’t believe there is imminent danger, the report said.

From 2009 through 2019, 532 Oregonians died in 393 fatal domestic violence incidents, the report said.

“I am horrified at the numbers in this report showing how pervasive and dangerous domestic violence is, both nationwide and in Oregon,” Secretary of State LaVonne Griffin-Valade said in a statement. “October is Domestic Violence Awareness Month, a time to recognize and reflect on what we can do to address this violence, and the auditors have done just that with this report.”

Auditors recommend state policymakers develop a statewide strategy that identifies and addresses the highest needs in the system.

They called on the state to centralize its approach and share information and data about approaches that work, including prevention and intervention strategies to help victims.

Auditors also recommended that legislators ensure that nonprofits that serve victims are stable by allocating regular, permanent funding that is adjusted for inflation rather than one-time grants that are unpredictable.