Sophia Crestani: Coroner finds death of student at Dunedin flat likely preventable

• University of Otago student Sophia Crestani died at an overcrowded Dunedin party in October 2019.
• An inquest into her death was held in May, with Coroner Heather McKenzie publicly releasing her findings on Tuesday.
• McKenzie found her death was a tragic accident, but says it was likely preventable with active oversight from the hosts.
• McKenzie recommends students hosting large parties take active steps to be responsible hosts and the university consider its approach to disciplining students.
• Crestani's family welcomed the findings, saying her death was "the end of the world" but she had a new job to reduce alcohol related harm.

A tragic, but likely preventable accident - that's how a Coroner has described the death of a student at an overcrowded Dunedin party five years ago.

Sophia Crestani, 19, died during a stairwell pile-up at a party hosted in the student flat known as The Manor.

An inquest into her death was held in Dunedin in May. Coroner Heather McKenzie delivered her findings in the city on Monday, under embargo until Tuesday.

McKenzie found Crestani died from crush asphyxia - when pressure to the chest prevents normal breathing. But she said there was at least half an hour when intervention could have saved her life.

"I find that Sophia's death was a tragic accident. However, Sophia's death was likely preventable because active oversight of the party by the tenants as hosts, or any guest phoning police if they had become aware of what was happening, might have led to it being controlled or shut down earlier, before it became a critical situation," she said.

McKenzie criticised the hosts of the party - who have interim name suppression - saying they should have taken an active role in overseeing and controlling their party rather than mostly confining planning to the pre-party stage, without focusing on guest safety on the night.

"It was not safe or responsible for some tenants to at times remain in secured rooms and to let their party grow on its own."

There was evidence some of those inside the ground floor closed off rooms knew people were asking to be let in, and they were not absolved of responsibility if they didn't foresee this happening or were in their rooms, she said.

Noise control had attended The Manor at least ten times from February 2019, with five excessive noise directions given during the same period.

McKenzie found the property manager overseeing the Manor, Jennifer Adamson, or landlord Heriot Holdings, should have considered terminating the tenancy after the university's proctor wrote about the risks of large parties at the house.

Adamson should have better communicated the safety messages to the tenants and the concerns raised to the landlord, she found.

McKenzie also found Otago University should have actively considered formally disciplining the tenants after the October 2019 party.

'End of the world'

McKenzie gave her findings to family, lawyers and public, with a photo a laughing Crestani captioned "Our Beautiful Girl" and a photo of her grave at the front of the courtroom.

Her father Bede Crestani welcomed the findings, but said his daughter had missed out on 60 to 80 years of life.

"Hearing 'rest in peace' is devastating. It's the end of the world," he said.

"She came here to be safe and grow and learn. She now looks like she does in the second photo (of the grave).

"The reason we're here today is to find out what happened to her and to look to the future and to make sure that all other students who come here in any way possible stay as the first photo."

He found it heartening to hear the coroner go through recommendations the family made, even though they were outside the scope of the inquest.

Her mother Elspeth McMillan said they wanted to see a culture shift in the wake of their daughter's death.

"The Dunedin student culture of overcrowded parties, excessive alcohol and drug consumption, anti social and risky behaviour is accepted as normal. It must continue to improve," she said.

She was pleased with the work to improve student safety and well-being in North Dunedin, but said the work was far from over.

McMillan wanted to see suitable on-licence venues, responsible off-licence rules, improved student rentals, litter solutions, urban designs, and sanctions for bad behaviour.

'People are going to die at the Manor tonight'

"Maggot Fest" was meant to be a last hurrah for The Manor before the university took over the lease the following year.

About 400 people were invited, with roughly 250 of the invitees indicating they would attend.

On 3 October, two tenants told Campus Watch about the party and were asked to sign up to the Good One register, which they did.

They designated three rooms to host the party, locking or boarding off the rest including closing off access to the back door, leaving one way in and out of the flat.

Plastic was put on the floor, rooms were cleared, a DJ area was set up and protected with an fence.

On 5 October, Sophia Crestani and a friend arrived at 9.30pm. The friend described a "good amount of people".

Not long later, Campus Watch described the party as appearing "very well contained and quiet".

But the party became busier as the night went on, and the atmosphere shifted from about 11pm. The stairs had become very crowded with loud music, poor lighting at times, and most people were drunk.

When Crestani tried to move upstairs for the last time, she fell and got caught up in the mass of people at the bottom of the stairs.

"People lost shoes. They could not move due to being squashed or having one part of their body trapped such as a foot. They had difficulty breathing. Some vomited. Some said they blacked out. Others could not see as they were trapped underneath people," McKenzie said.

"People were screaming and crying. There was a large weight of people such that the crowd started to sway. Some people had no control of their balance/footing."

One party-goer who was trapped in the pile described Crestani as looking scared before calm and "really vacant".

Eventually, another party-goer managed to free her and carried her out of the house, putting Crestani down on the footpath at the direction of the police who were called by Campus Watch just before midnight.

An excessive noise direction had been served about 10 minutes earlier.

Students had also started calling 111 in a panic with another partygoer texting his friend: "Mark my words people are going to die at the manor tonight from suffocation".

Crestani was given CPR by police until ambulance staff took over but she could not be revived and died at the scene.

Coroner's recommendations

• Students hosting large parties should take active steps to be responsible hosting including registering their party and monitoring number and the atmosphere on the night.
• Students leave parties or call authorities if they don't feel safe.
• The university considers its approach to disciplining students after large events that breach its Code of Conduct, what penalties it imposes, and communicates directly with students on significant matters.
• Campus Watch staff get new or regular refreshing training about assessing risk at large student parties and is clear with students about the limits of what they can do to help.
• Party registrations include a trigger if they are over a certain size or others risks for authorities to discuss safety precautions with the hosts.
• The Good One website removes the recommendation to lock bedroom doors at a party.
• The Otago University Students' Association better integrate information about being safe at parties, the risks of intoxication and how to safely host parties into its student orientation and flatting resources.

McKenzie said some of the recommendation might seem improbable or naïve, but they were aimed at preventing further deaths and being aspirational.

"May Sophia rest in peace. But may she also be seen within the actions her loved ones and interested parties are taking to honour her legacy and to help make North Dunedin a safer place for students. I wish the parties the very best for their work towards achieving this," she said.

Sophia Charter

The University of Otago has recommitted to its pledge to support students and reduce harm.

The Sophia Charter was created in the wake of her death to enhance safety and well-being of students living in North Dunedin.

University Vice Chancellor Grant Robertson said all agencies remained committed.

"To making sure that we uphold a safe and inclusive environment for students and that we enhance the well-being of students while they're at the University of Otago," he said.

"You have my personal commitment as Vice Chancellor, that that is something that I will be doing."

The university would be carefully working through the 158 page findings and recommendations before deciding what next steps to take, he said.

The university had already started the work to improve life for the North Dunedin student community but there was still more to be done, Robertson said.

"There is an inherent tension in how involved the University should be in the lives of students. Our approach to safety, well-being and discipline in North Dunedin is constantly evolving and we will continue to develop it as suggested by the Coroner."

A scholarship in Sophia's name was established by the family for a female second-year student studying mathematics and/or statistics.