Delivering her findings verbally in the Dunedin Coroner’s Court, Coroner Heather McKenzie began by acknowledging a photo of Crestani alongside a photo of her headstone that sat in front of the courtroom.
Crestani’s parents, Bede and Elspeth, and her twin sister Frances and her partner, sat at the front of the courtroom during the proceedings. Her brother, James, attended through audio-visual link.
The findings were delivered yesterday - the day following the five-year anniversary of Crestani’s death. A memorial service was held at the University Link on Sunday.
A photo of Sophia Crestani, alongside a photo of her headstone, sat before the Dunedin Coroner's Court during an inquiry into her death. Photo / Ben Tomsett
A forensic pathologist determined that the pressure from the crowd restricted Crestani’s ability to breathe, she said.
Toxicology reports revealed that Crestani had a blood alcohol level of 135mg/100mL, above the legal driving limit, but the pathologist concluded that alcohol did not physiologically contribute to her death.
The time of death was declared at 12.25am on October 6, but it’s unclear if she died before or after midnight.
McKenzie noted that police had conducted an extensive investigation of events, collecting over 160 statements from partygoers and other relevant individuals.
Witnesses provided detailed accounts through the inquest, though many struggled with memory lapses due to the passage of time and the nature of the event, she said.
McKenzie emphasised that Crestani’s death was a tragic accident and not a result of deliberate negligence.
Coroner Heather McKenzie at the inquest into the death of Sophia Crestani. Photo / Pool
The tenants, who hosted the party, acknowledged taking some steps to ensure safety, such as blocking access to the balcony, but they did not foresee the eventual outcome, she said.
The Manor was a well-known student flat and had previously received warnings from Dunedin City Council (DCC) and University of Otago officials about safety and noise, including for a 300-person party in July that year.
Noise control officers issued multiple excessive noise directions, and the DCC contacted the property owner about ongoing disturbances, she said.
Concerns about overcrowding, safety, and damage to the property were repeatedly raised, and following the July party, the university proctor warned of the risks posed by hosting such large events.
Sophia Crestani. Photo / Supplied
Coroner McKenzie said that while co-operative with authorities, the Manor tenants continued to attract attention.
In her findings, Coroner McKenzie recommended that students hosting large gatherings take steps to act as responsible hosts.
“This includes registering their parties with Good One and Campus Watch, monitoring attendance and party conditions, designating a sober individual to handle emergencies, and contacting police if necessary,” she said.
“Proactive management during a party can help mitigate potential hazards, such as overcrowding or a deteriorating atmosphere.”
She recommended that the university should reconsider its disciplinary approach for large events that breach the Code of Student Conduct, particularly those that create risks to individuals or property.
“Additionally, I recommend that Campus Watch receive refresher training on assessing risks at large parties and be transparent with students about their limited ability to intervene. A better understanding of these limitations could prevent a false sense of security among students.”
Sophia Crestani's family members (from left) aunt Mel Beirne, parents Elspeth and Bede Crestani, and cousin Ashleigh Bruce at her memorial at the University of Otago on the five year anniversary of her death. Photo / Ben Tomsett
Finally, she recommended that the OUSA further integrate safety advice into its orientation and flatting resources, and that the Good One party register include a mechanism for in-person meetings between event hosts and relevant authorities.
McKenzie emphasised that establishing these facts holds significant meaning for Crestani’s parents, and that the inquest’s recommendations reflected the ongoing efforts by her family, particularly around the creation of the Sophia Charter, aimed at addressing student safety.
McKenzie reiterated Bede Crestani’s comments during the hearing phase of the inquest: “I think we’ve learnt through this week that there is no simple answer to anything. It’s a whole system and community-wide set of issues.”
McKenzie said she recognised the emotional toll Crestani’s death has taken on all those involved, especially the tenants and the witnesses who testified.
“Most witnesses were deeply affected by the event, and their testimonies reflected the passage of time and the gravity of the situation.
“At the inquest, Mr Crestani said that Sophia had a new job to do regarding alcohol-related harm, and that he ‘hopes she has a long life through that’. No doubt Sophia’s legacy will continue to resonate amongst the living in many other ways too.
Bede and Elspeth Crestani outside the Dunedin Coroner's Court following an inquest into their daughter Sophia's death. Photo / Ben Tomsett
“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.”
Following the coroner’s closing remarks, Bede and Elspeth spoke to media outside the court.
“Sophia’s death was a preventable, if tragic accident,” Elspeth said.
“We are disappointed that the tenants didn’t acknowledge or take any responsibility for the role, that their actions or lack of actions contributed to Sophia’s death, but rather had collective memory loss at the inquest.”
Bede acknowledged that the tenants were not present for the coroner’s findings.
Elspeth said that Dunedin has a “unique” situation that requires unique solutions.
She said that some landlords were exploiting students for profit and turn a blind eye to anti-social and risky behaviour in their properties.
“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 also said there needed to be sanctions for outlier student behaviour.
“If there are no sanctions, why would they change? Why would they stop?”
Bede Crestani said that the day still did not bring closure for their loss.
“Hearing ‘Rest in peace’ for your daughter is just devastating. How do you ever? It’s five years. It’s still just heartbreaking to hear those words.”
The parents said they would now be putting most of their energy into the Sophia Charter, a stakeholder group comprised of the University of Otago, Otago University Students’ Association (OUSA), Otago Polytechnic, the Police, the Dunedin City Council, Fire and Emergency New Zealand and the Otago Property Investors Association.
The charter’s focus is student safety and wellbeing and aims to ensure that North Dunedin is a strong student neighbourhood where residents take responsibility for themselves, each other and the wider community; it will be a place that is fun, vibrant, safe and secure and that fosters student success and wellbeing.
University of Otago vice-chancellor Grant Robertson, who was present during the findings, also addressed the media.
“We will work through those recommendations... I think it is really important that the university continually reviews its processes, and that includes around areas like discipline, around how we interact with students.
“It’s important to acknowledge that, but also that there’s always more to do to make sure that we do create the safe and inclusive environment here in Dunedin that we all want.
“I do believe for the vast majority of students who come here ... they work hard, they get their degree, they meet friends for life, and they have a good time. Unfortunately and tragically in this case, in the rare circumstances, things go wrong, and we’ve got to do everything we can to make sure that that doesn’t happen again.”
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