A coroner has recommended activities at a far north Queensland tourism operator be suspended until a safety audit was undertaken, following the death of a German tourist in 2011.
In a damning assessment, coroner Jane Bentley said the Granite Gorge Nature Park, about 15 kilometres south-west of Mareeba, posed a "clear and present danger" to public safety.
Nineteen-year-old Navina Friedericke Villinger, from Hamburg, drowned on January 10, 2011, after she was caught in a current at a Granite Gorge creek and swept into an underwater cave system known as the "Bat Cave".
Ms Villinger's body was found two days later about 6.20pm on January 12.
She had arrived at the privately run Golden Gorge Nature Park with four friends – three German and one Australian – about 4.30pm and went for the fateful swim shortly afterward.
Jennifer Connell, the Australian in the group, was also swept up by the current, but managed to survive in a pocket of air in the underground cave system.
She suffered several injuries, including bruising and broken toes.
Ms Connell told the inquest one the park's operators, Coleen Bryde, had handed them a map when they arrived at the park, but had not said anything about "safe" and "unsafe" areas in which to swim.
"During her interview (with police and Office of Fair and Safe Work Queensland officers) on 11 February 2011, Mrs Bryde was asked about risk management at the park," Ms Bentley said in her published findings.
"It was clear she did not have any knowledge of the concept.
"She said she knew of the Workplace Health and Safety Act, but had not read it."
Ms Bentley said Mrs Bryde could not point to any formal safety policies or procedures that were in place at the park at the time of Ms Villinger's death.
"She said she decides where people can swim depending on the depth of the water and how fast it is running," Ms Bentley said.
Mareeba Police district officer Rolf Straatmeier, who coordinated the search for Ms Villinger, told the inquest he used the map that was given to the five friends some time after the German's death.
"Inspector Straatmeier attempted to navigate his way around the park using that map but he found it confusing and he had difficulty identifying the land marks depicted on it," Ms Bentley said.
"He and another police officer together tried to navigate the park with the map but were unable to do so."
Inspector Straatmeier told the inquest he was "deeply concerned for the safety of people who would visit there in the future".
"Navina Villinger and Jennifer Connell could not have known the danger of which lay not 20 to 30 metres from where they initially left their towels," he said.
"There was no warning sign, nothing to alert them to any danger whatsoever.
"What contributed to the danger was that the main feeding rock for the wallabies was right next to the sieve. There was no fence, no signs."
The inquest also heard there had been no maps made of the cave system into which Ms Villinger and Ms Connell had been swept, which would have been useful for the rescue mission.
"Granite Gorge Nature Park poses a clear and present danger to public health and safety," Ms Bentley said.
"…In 2008, Mr (Keith) and Mrs Bryde were advised by QFES that they should develop emergency procedures and conduct risk safety assessments.
"They did nothing.
"The 'Accident Procedure' document Mrs Bryde provided to OFSWQ during the investigation into the death of Ms Villinger reveals that either she was totally ignorant of appropriate safety procedures (in which case she should have engaged an expert consultant) or that she treated her responsibilities and any advice she was given with utter derision.
"The fact that she largely ignored all advice offered to her, even after the death of Ms Villinger, strongly suggests the latter."
Ms Bentley said Mrs Bryde had chosen to "abdicate responsibility" for the death of Ms Villinger and the injuries to Ms Connell.
"(Mrs Bryde) has continuously, obstinately and unreasonably refused to address, in any meaningful way, the issue of safety at her business," Ms Bentley said.
Ms Bentley said the evidence of Inspector Straatemeier indicated Mrs Bryde was "unwilling to accept any responsibility for the drowning of Ms Villinger and remained of the opinion that Ms Villinger and Ms Connell were at fault because they had not listened to what she had told them".
"The park poses a significant risk to the health and safety to persons who visit it," Ms Bentley said.
"Visitors should be prohibited from undertaking activities in the park including swimming, bushwalking and 'rock-hopping' until the risks posed to visitors have been addressed.
"Mr and Mrs Bryde have shown that they are unable and/or unwilling to address those risks in any appropriate way."
After its investigation, the OFSWQ chose not to proceed with a prosecution against Granite Gorge Nature Park based in part, Ms Bentley said, on "the premise that Mrs Bryde had no history of non-compliance".
"Investigators were unaware of the numerous incidents that had occurred in the park prior to Ms Villinger's death which had resulted in visitors to the park being injured and/or requiring rescue," she said.
Ms Bentley recommended the OFSWQ re-open its investigation into Ms Villinger's death.
She also recommended a prohibition notice be issued to Granite Gorge Nature Park preventing activities in the park until OFSWQ officers were satisfied there had been adequate risk management undertaken.
