The 9-year-old daughter of a Kiwi who was one of people four killed in the 2016 Dreamworld tragedy in Australia has shared a heartfelt tribute at her mother's inquest.

Coroner James McDougall today handed down his long-awaited findings from the inquest, totalling 300 pages, into the deaths of four people on a ride at Dreamworld more than three years ago.

He said there was a "systematic failure" by Dreamworld in relation to "all aspects of safety".

Cindy Low, originally from Kawerau, along with Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the Thunder River Rapids malfunctioned at the theme park.

Advertisement

READ MORE:
Dreamworld tragedy: Queensland coroner to release findings into fatal ride
Dreamworld finally starts demolition of ride that killed four people
The horrific images Dreamworld first responders saw on that disastrous Thunder River Rapids ride
What you haven't heard from Dreamworld inquest

Isla Low was just six when her mother was killed while on the ride with her brother, Kieran, on a family day out at the theme park.

"Mum was a wonderful person with a very big heart," the now 9-year-old said in a statement read out by her father, Mathew Low, in the Brisbane Magistrates Court today.

"I miss her hugs and the cakes she used to make."

Matthew spoke of the "unconditional love" his wife - born in New Zealand but who lived in Sydney - had for family and friends.

"Our hearts ache daily as we try with varying success to be grateful for the decades we had.

"She had the heart of a tiger, fierce and protective."

Kiwi mum-of-two Cindy Low lived in Sydney for at least a decade with her Kiwi husband, Matthew, who was originally from New Plymouth. Photo / File
Kiwi mum-of-two Cindy Low lived in Sydney for at least a decade with her Kiwi husband, Matthew, who was originally from New Plymouth. Photo / File

The inquest also heard a statement from Low's mother, who was in New Zealand when she received the news, read by her lawyer.

Advertisement

"I collapsed. She was dead," the Brisbane Times reported.

The inquest heard of the impact her daughter's death had taken on her.

"Since Cindy's death, I have become a reclusive old lady. I feel no interest in anything."

She had to take pills to get her through the day, and then to sleep, the Brisbane Times reported.

"I miss her so much and I can't wait to see her again."

She also told the inquest how she had written a note to the young ride operator.

"I know my daughter wouldn't want her to carry the burden," she said.

Earlier, the inquest heard from Low's brother, who told the court he was working in New Zealand and heard the news on the radio, and was glad to think it wouldn't be someone he knew, the Brisbane Times reported.

The next day his mother called, telling him his sister had died.

"She just made our lives better," he told the court.

Police recommended no criminal charges against Dreamworld staff over the fatal incident.

Coroner James McDougall today referred Ardent Leisure, the owner and operator of the Gold Coast theme park, to the Office of Industrial Relations to consider whether there is sufficient evidence to show it committed breaches under workplace laws.

He said there was a "systematic failure" by Dreamworld in relation to "all aspects of safety".

Three of the four victims were flung instantly into a mechanised conveyor when their raft collided with another and partially flipped on October 25. A crucial delay in manually stopping the ride caused the jammed raft to shake, plunging a fourth person into the machinery.

The inquest heard the malfunction was the third that day and the fifth in a week.

Inexperienced staff panicked, sending out a radio call stating there was a "raft in the conveyor" - the first indication something disastrous had happened, the inquest heard last year.

Despite the efforts of paramedics, the four had no chance of survival. Goodchild's 12-year-old daughter and Low's 10-year-old son survived the incident.

The wide-ranging inquest, which opened in June 2019, revealed a "litany of problems" with some experts declaring the tragedy was an "accident waiting to happen".

Australia and New Zealand await the coroner's Dreamworld decision. Photo / Supplied
Australia and New Zealand await the coroner's Dreamworld decision. Photo / Supplied

Dreamworld's training systems were heavily criticised, with revelations staff operating the ride on the day of the disaster were given just 90 minutes of training.

A memo sent to staff days before the tragedy warned the emergency stop button should not be pushed.

To cut costs, Dreamworld also stopped spending money on repairs and maintenance in the months before the fatal accident.

Staff admitted there had been a "total failure" to identify risks with the ride and a series of equipment failures before the accident should have been investigated.

The ride was also heavily criticised as "unsafe" with no proper maintenance schedules, extensive cracking and corrosion, with parts of the structure "propped up with timber".

Theme park staff removed slats from the conveyor belt and made unapproved structural alterations to the attraction that had been installed more than 30 years previously.

The Queensland government pre-empted the inquest findings, introducing new safety regulations for amusement rides, including mandatory major inspections of rides by qualified engineers every 10 years and improved training for ride operators.

The state also tightened workplace health and safety prosecution laws.

It is meant to be one of the happiest places in Australia - a place where all the family can come together for fun, laughter and rides that thrill. But Dreamworld is waking to a nightmare this morning. Four people dead - with reports one of them is a New Zealander.

THE VICTIMS

• Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi were killed when Dreamworld's Thunder River Rapids ride malfunctioned on October 25, 2016.

WHAT HAPPENED

• Two rafts collided on a conveyor when a water pump failed and caused water levels to drop dramatically.

• The malfunction was the third that day, and fifth in a week.

• The victims' raft was pushed into a vertical position and the victims plunged into the ride machinery, causing fatal injuries.

RIDE HISTORY

• Police uncovered multiple previous incidents with the ride, including a guest being thrown into the trough in 2004 when rafts collided.

• Despite recommendations for a single emergency stop, no single shutdown function was installed.

STAFF TESTIMONY

• Dreamworld electricians described the control panel wiring as a "rat's nest".

• Staff insisted the ride was one of the most complex to operate.

• The operator in charge on the day was given only 90 minutes of training.

• A supervisor said pump failures were frequent in the week preceding the tragedy.

• Staff were unaware of the theme park's policy to shut down an attraction after two failures in 24 hours, believing a third was needed for a supervisor to be notified.

• Engineering general manager admitted the ride "should never have opened" after the malfunctions.

OTHER EVIDENCE

• Government registration of Thunder River Rapids and other rides at the park were more than nine months overdue.

• Dreamworld executives announced cutbacks to maintenance and repair spending in 2016 due to falling profits.

•Workplace Health and Safety inspectors identified a "litany of concerns' on the ride's maintenance, including missing slats on the conveyor belt, excessive corrosion, crumbling concrete and unidentified controls.

• Modifications made to the attraction had never been approved by WPHS.

WHAT THE VICTIMS' FAMILIES HAVE SAID

• Relatives of two victims said in a statement they held Dreamworld "totally responsible" for the deaths.