A Queensland coroner says criminal charges could be laid against Dreamworld’s owner Ardent Leisure following the 2016 tragedy that killed four holidaymakers.

Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the Gold Coast theme park ride malfunctioned.

Coroner James McDougall handed down his findings into the deaths of four tourists on Monday, saying Dreamworld had presented itself as a modern world-class theme park but its safety procedures were rudimentary at best.

He referred Ardent Leisure to the Office of Industrial Relations to consider whether the company might have committed an offence under workplace laws.

“There was a systemic failure by Dreamworld in relation to all aspects of safety to ensure that rides … were well maintained and safe,” he said.

Mr McDougall described the theme park’s systems as “frighteningly unsophisticated”.

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

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

He also found there was no evidence Dreamworld conducted a thorough engineering risk assessment of the ride in the three decades it was open to the public.

“I find that shoddy record-keeping was a significant contributor to this incident … [and] contributed to the masking of the real risk of the [ride],” he said.

“Failure to record the changes have contributed to the masking of the real risk of the [ride].”

More than 100 people packed the Brisbane Coroners Court on Monday to hear the long-awaited findings.

From left: Roozi Araghi, Luke Dorsett, Kate Goodchild, and Cindy Low died on the ride in 2016. Photo: ABC

Ms Low, Ms Goodchild, Mr Dorsett and Mr Araghi died after being flung into a mechanised conveyor when their raft collided with another and partially flipped.

Ms Goodchild’s 12-year-old daughter and Ms Low’s 10-year-old son survived the incident.

Before Mr McDougall handed down his findings, Ms Goodchild’s and Mr Dorsett’s mother Kim Dorsett spoke of her grief, saying her greatest regret was not being there for her children on the day they needed her most.

“I wasn’t there,” she said, wiping away tears.

“The easier part was burying them, the harrowing part is living without them.”

The pair’s father, John Goodchild, said his grief was exacerbated after learning the malfunction on the right could have been identified before the accident.

Matthew Low, the husband of Cindy Low, said his heart ached daily. He also also read out a statement from the couple’s nine-year-old daughter, who wrote she missed her “hugs and cakes that she used to make for us”.

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

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

Police uncovered multiple earlier incidents involving the ride, with two rafts colliding in 2004, throwing a guest into the trough.

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

Since the accident, Queensland has introduced new safety regulations for amusement rides, including mandatory major inspections by qualified engineers every 10 years and improved training for operators.

The state has also tightened workplace health and safety prosecution laws.

Premier Annastacia Palaszczuk has promised the government will seriously consider the coroner’s findings.

“Anything that is recommended today we owe it to those families to make sure it is implemented,” she told Nine’s Today program.

-with AAP