8 key points from Dreamworld inquest
"CODE 222 blue. I've got a raft on the conveyor."
They were the only words a Dreamworld employee told the park's security office in a call for help the day of the Thunder River Rapids Ride disaster.
When the employee hung up, security officer Nigel Irwin was left trying to find out what caused the code 222 blue - the theme park's code for a medical emergency.
In the past week shocking and horrifying details of the park's emergency response have unfolded in the Coroner's Court of Queensland at Southport as the inquest continues into the October 25, 2016 tragedy.
The inquest is examining what happened about 2pm, when a pump stopped working on the Thunder River Rapids Ride, causing water levels to drop and a raft to become stuck on the conveyor belt.
That raft was hit by another carrying Luke Dorsett, his sister Kate Goodchild, her daughter Ebony, 12, Roozbeh Araghi, Cindy Low and her son, Kieran, 10.
The four adults were killed. The children escaped uninjured.
The inquest this week has focused on what the emergency responders at the park saw as well as the safety policies and processes in place.
THE UNKNOWN PATIENT
EXPERIENCED paramedic John Clark had worked with ambulance services in the UK and in Queensland but 20 years of experience still could not prepare him for what he was confronted with when he arrived on the scene after receiving the emergency calls.
The paramedic was the first clinician on scene after hearing the alarm when he was in the park's nearby clinic in the Gold Rush area.
Mr Clark told the inquest he knew he could not help two of the victims he saw when he arrived but saw a man trying to give CPR to a person in the water.
Mr Clark waded into murky, chest-high water to help, asking for something to use to get the patient out of the trench.
While he was working on that patient, the water was dropping, revealing a fourth person in need of help.
Mr Clark said he did not know how long he had been at the scene before he became aware of the fourth patient.
"If I could tell you a time … I couldn't tell you … I'm really sorry," he told the inquest.
While Mr Clark was working, first aid boss Shane Green was racing over from the clinic at White Water World.
"I guess from our point of view, we would have never envisaged something like that occurring," he said.
Mr Green said the scene was so horrific that it "overwhelmed" the experienced paramedics, Queensland Ambulance Service officers and police officers.
"Up until that particular case we were very confident that we had a cracking team," he said.
"There is nothing anyone else would have done in that particular case."
Dreamworld registered nurse Rebecca Ramsey arrived soon after the call, running over with no equipment as she was on a shift as a safety officer that day.
"When I arrived on the scene someone handed me a small child," she said.
"I took that child out of the ride area."
She then returned to the scene to help and tried to find out how many people were on the raft.
No one knew.
Ms Ramsey said there was one thing she noticed - the absence of the rapids ride alarm to alert first-aid staff there was a medical emergency.
"I feel that if the alarm had have been sounded by the operator then we may have had a more wider response, then more people would have been there sooner," Ms Ramsey said.
"There was a bit of a delay between the code 222 blue and the code 222 grey (medical emergency involving mechanics) … even though it was pretty quickly … I just think pushing the alarm would have had a more rapid response."
While they worked, security officer Nigel Irwin was in the control room, trying to relay information to ambulance officers so they knew what they needed when they arrived.
"There was one person on the conveyor and one unconscious turning blue," he told them.
MR Irwin had to sit through watching horrific footage of the incident numerous times to help police gain an understanding of what happened.
The security officer had been manning the CCTV cameras.
"I obviously had police come and take over the control room … every officer wanted to see the footage. Every senior officer wanted to see the same thing," he said.
"I watched it numerous times forward, backwards and the same thing. It was quite distressing."
Mr Irwin said he backed up the CCTV footage before deleting it from Dreamworld's system.
TRAINING 'FOBBED OFF'
REBECCA Ramsey tried numerous times to organise regular morning training for staff before the park opened.
Barrister Matthew Hickey, for victim Cindy Low's family, asked: "Was there some resistance from management getting staff in for training?"
Ms Ramsey replied: "Yes."
She was asked if she felt she was being "fobbed off".
"Sometimes," she replied.
First-aid boss Shane Green said he had similar experiences.
"To do it before the park was open would have involved bringing people in before their shift, which would have involved extra cost," he said.
"We were under quite strict guidelines in regards to our wage for training."
LAWYERS for Dreamworld dumped more than 1000 documents consisting of "thousands of pages" on the counsel assisting the coroner on Monday.
By Friday it was clear the release of those document might mean some witnesses may be forced to relieve the horrific day again and be called to the stand for a second time.
Efforts to process the documents were hampered by a power outage at the Southport Courthouse.
Barrister Steven Whybrow, acting for David Turner, the partner of Kate Goodchild, and Shayne Goodchild, the father of Ms Goodchild and Luke Dorsett, said he was concerned by the lack of documents supplied about investigations into a November 2014 incident which had eerily similar circumstances to the tragedy.
"The lack of any documentation following some incidents is of great concern to my clients," Mr Whybrow said.
He said an email already produced claimed an investigation was launched by Dreamworld.
"One way or the other it's time to clarify whether there are any documents or not," he said.
Bruce Hodgkinson, barrister for park owner Ardent Leisure, said there were difficulties due to the volume of documents Dreamworld had.
"We have had four people full-time going through materials. There are 600,000 emails," he said.
The production of the new documents meant the inquest was forced to adjourn early on Thursday to allow barristers time to go through the material.
THE maintenance planner at Dreamworld said "everybody" had failed to identify the safety issues on the Thunder River Rapids Ride.
Counsel assisting the coroner Ken Fleming asked maintenance planner Grant Naumann: "Whose job was it to determine the safety of a ride like this?"
Mr Naumann: "Everybody's."
Mr Fleming: "Are you saying there has been a total failure by everybody in determining the safety issues of this ride?"
Mr Naumann: "In hindsight, yes."
EIGHT days before the Dreamworld disaster, the Thunder River Rapids Ride was certified as mechanically sound by machinery inspector Tom Polley.
"A visual inspection of the device (including a specific inspection of visible mechanical and structural critical components) has been completed. This inspection did not include an electrical inspection," the document reads.
"In my opinion, this device was mechanically and structurally safe to use at the time of inspection provided the above recommendation is appropriately considered and the above fault found is repaired."
The document was dated October 17, 2016.
The fault was an issue with the anti-rollback gate not working and the recommendation was it be added to the inspection.
CULTURE OF FEAR
DREAMWORLD staff were fearful of their supervisors and were getting kidney infections because it took too long for someone to relieve them so they could go to the bathroom, a union representative claimed in an email to Dreamworld.
Union representative Jared Drysdale also alleged supervisors were "out to get" staff.
"It has also brought up talk about staff having to pee at their rides, leaving their rides unattended and even being hospitalised with a kidney infection because of personals taking to (sic) long," the email said.
"But my major concern about this is in regards to the point I am trying to make is that staff say, supervisors don't care and are just out to get you."
SOME Dreamworld employees will be lodging legal action to get compensation for the psychological trauma they suffered from the tragedy, personal injuries solicitors Shine Lawyers announced on Monday.
The announcement led to counsel assisting the coroner Ken Fleming to slam the firm as "opportunistic".
He later apologised and withdrew his comments.
"It's entirely inappropriate to confuse this procedure with a common law procedure and it's entirely inappropriate in respect of this procedure," he said.
"This must stand alone."
Mr Fleming said it was important for the inquest to focus on the victims, their relatives, Dreamworld employees and Ardent Leisure.