A scathing report describes Queensland's coronial system as failing and under stress, with a backlog of cases two years or older.
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It reveals a shocking case, where a government undertaker was allegedly late to transport a body, did not show compassion to a grieving family, damaged their floors, and had a "disgusting mess" of a van.
The Queensland Audit Office investigation, by auditor-general Brendan Worrall, spoke to senior people across the coronial system who said they believed it was "failing".
The coronial system involves the Coroners Court, forensic and scientific services and the Queensland Police Service and investigates deaths that occur under certain circumstances.
The audit found the system lacked cohesion, with no one agency responsible for leadership, accountability, planning and reporting across the system.
Its report found excessive delays and a declining clearance rate were leading to a growing backlog of coronial investigations, indicating the system was "under stress".
Coronial cases that were 24 months old or older increased from 7 to 16 per cent over the past six years.
"We found that Queensland's coronial system is struggling to keep up with demand and is not consistently providing timely and effective support to coroners," the report found.
Despite the best efforts of people working in the coronial system, the communication and support provided to grieving families was inadequate, with a lack of clearly-defined leadership, accountability and lack of integration between agencies systems' contributing to the breakdown, the QAO said.
In some cases, families were not spoken with again after the very beginning of the process, despite the investigation taking more than four years to finalise.
The report reveals a shocking case in March 2018 in which police claim an undertaker lacked compassion and knowledge about handling the body, which caused distress to the family
The undertaker used faulty and broken equipment that damaged the family's timber floorboards and his van, used to transport the body, was a "disgusting mess with what appeared to be dirty laundry and there were no points to secure the trolley or body", police claimed.
Officers reported the government undertaker's conduct to the Coroners Court. There had been other complaints about the undertaker's performance when transporting bodies.
The Coroners Court called the government undertaker to discuss the matter, and the undertaker apologised but dismissed some matters. The court did not investigate the matter further, and the undertaker continued to provide coronial transport services.
In April 2018, another complaint was made, which the Coroners Court was investigating.
In addition, the report found court staffing was inadequate for the volume and nature of work staff performed across the state.
Coroners Court staff received no training in communicating with and supporting distressed families, and with a high staff-to-manager ratio of 25 to one, it was difficult for managers to provide enough support.
A spokeswoman for Attorney-General Yvette D'Ath said the government would consider all the recommendations from the audit.
"The Department of Justice and Attorney-General is already making changes to the Coroners' Court processes, after conducting its own organisational review, and as part of those changes we've funded six extra positions in the Coroners Court," she said.
The spokeswoman said work had already begun to improve case management processes, address backlogs and enhance the support provided to coroners and bereaved families.
