The coroner says laws on the prosecution of industrial deaths in South Australia need reform.
His comments form part of his findings into the death of teenager Daniel Madeley.
The 18-year-old man died after he was pulled into a drilling machine in 2004 at an Adelaide factory.
Coroner Mark Johns said it was wrong that it took five years before the company, Diemould Tooling, pleaded guilty to workplace safety breaches.
He said there needed to be an open public inquiry within 12 to 18 months of an industrial death.
