A Queensland coroner has issued findings of an inquest into the deaths of four people at the Dreamworld theme park.

Queensland south-eastern coroner James McDougall handed down his findings into the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi, who died when a ride malfunctioned at the park.

The report covers issues seen as contributory to the tragic events, going back over an extended period of time.

These included confusion within the company as to whose responsibility was what, a lack of focused safety auditing, problems with the availability of suitably qualified ride consultant engineers, a lack of clarity in Australian Standards linked to rides, shortcomings in regulatory oversight, a lack of training for staff and an overall lack of systems and processes within the company (which Dreamworld operator Ardent Leisure pre-emptively rejected prior to any finding, relating to systems of training, or lack of record-keeping), and a host of other issues.

“[There were] frighteningly unsophisticated systems in place at Dreamworld,” Mr McDougall said.

“It was simply a matter of time. That time came on October 25 [2016].”

He found there was no proper engineering oversight, nor had the Thunder River Rapids ride ever undergone any holistic risk assessments.

“Whilst there were various occasions … hazard identification risk assessment should have been triggered … this was never done,” the coroner said.

“Owners should be risk-averse. That was not the case with respect of [this ride].

“Dreamworld placed significant reliance on ride operators to identify risks of issues.

“It is unfathomable that this serious and important task fell to staff … who didn't have the requisite qualifications or skill sets to identify such risks.”

The Coroner made two referrals; the first is to refer Dreamworld’s owners Ardent Leisure to the Workplace Health and Safety Regulatory Authority noting that “it is reasonably suspected that Ardent Leisure may have committed an offence under the workplace law”.

Secondly, the Coroner has referred an Engineer to the Board of Professional Engineers of Queensland, for failures linked to issuing of a plant (ride) renewal Certificate.

John Osburn, CEO of Ardent Leisure, said “safety is our number one priority”.

“I've been the CEO of Dreamworld for just over 12 months and I'm proud to be leading a new leadership team consisting of experienced and well-regarded executives from the theme park and commercial Australian aviation industries,” he said.

“Not a day goes by where the new leadership team does not think about the events of October 2016 and this makes us fiercely determined to do everything possible to make sure such a tragedy never happens again.”

The full report is accessible in PDF form, here.