The electronic footprints of a Canterbury University student who lay dead for weeks before being found have been outlined at a coronial inquest into his death.

﻿An independent investigation has revealed a series of failures that led to university hall student Mason Pendrous' body being undiscovered for weeks. SAM SHERWOOD reports on its findings.

When teenager Mason Pendrous applied for a place at one of Canterbury University's student halls, he described himself as a social person who liked to spend time with people.

But a few months into his studies, the 19-year-old described by one friend as "a tall silent giant" disengaged from his studies and spent most of his time in his Sonoda Village room on his computer, usually with the door shut. He rarely ate the provided meals in the shared dining room.

Supplied Mason Pendrous' death made headlines around the world after it was revealed he had been dead for up to a month before his body was found.

University staff sent him emails as he began to fall behind in his studies. His accommodation provider was also sent reports noting concerns about his progress.

The availability of online tuition and students spending increasing amounts of time socialising online from the privacy of their rooms meant Pendrous' isolation was not necessarily unique. Nor was his failure to engage in his studies, with over 100 students achieving concerning grades.

Campus Living Villages (CLV), an international firm that makes millions managing Sonoda and other student halls, largely relied on students to come to staff and Residential Assistants (RAs) with any problems, rather than proactively seek them out.

DAVID WALKER/STUFF Coroner Sue Johnson findings into Pendrous' death say the cause cannot be determined due to decomposition.

The result was that Pendrous' body lay undiscovered for potentially four weeks, until his stepfather arranged for Pendrous' friends to get a fellow student to look for him.

That delay meant his body decomposed to the point where the cause of his death could not be determined.

Former High Court Judge Kit Toogood QC, who the university commissioned to investigate how a dead student could go unnoticed for so long, released his 31-page report on Friday.

Supplied Pendrous and his stepfather, Anthony Holland.

The failures he identified included that CLV did not chase up concerns about Pendrous' academic engagement, and a restructure that left no staff on site.

READ MORE:

* The death of Mason Pendrous: Uni halls a 'ticking time bomb'

* Concerns about student found dead at university hall raised months earlier

* Cause of student Mason Pendrous' death will remain a mystery, coroner rules

* Six-week inquiry into University of Canterbury student's death

WHY MASON WASN'T FOUND

CHRIS SKELTON/STUFF Campus Living Villages managing director John Schroder says the company owes it to the Canterbury student and his family to find out what happened. (First published on September 26)

Toogood said the "principal reason" for the delay in discovering Pendrous had died was that fellow Sonoda residents and CLV staff did not notice his absence from August 26 (his last computer activity) to September 23 (when he was found dead).

Several factors contributed to this, including the closure of the CLV office at Sonoda from the beginning of 2018.

Toogood said if a CLV staff member – whose duties included getting to know residents and having face-to-face contact with each of them – had been at the Sonoda office during daylight hours on weekdays, Pendrous' absence would more likely have been noticed and his death discovered earlier.

JOHN KIRK-ANDERSON/STUFF Pendrous' body was found at the Sonoda Christchurch Campus on September 23.

He found the absence of regular "without cause" room checks by cleaners or RAs should be reconsidered. Such checks may have resulted in someone finding Pendrous sooner, or an earlier diagnosis of any illness. CLV does not clean students' rooms.

Pendrous' decision to stay in his room for long periods and not mix with other residents meant those who lived closest to him believed he was away.

At the end of July, university staff gave CLV's senior manager information about students who were struggling academically, including Pendrous.

In late July, it was told Pendrous was not engaging with the university's LEARN management system.

University staff asked the manager to check if Pendrous and other students were still living at the halls. Historically, CLV's managers and staff had acted within just a few days of receiving such information. This time, CLV did not act, despite a reminder to do so.

On August 26, semester two ended.

"It [CLV] did not make any attempt to contact Mason about those matters until 18 September 2019," Toogood found.

By then Pendrous was dead. His body was found five days later, on September 23. The Coroner ruled he died sometime between August 26 and September 10.

Toogood found CLV's failure to follow up on the information university staff provided was "inconsistent with the accepted practice".

Doing so would "likely to have led to a face-to-face contact with Mason prior to the commencement of the mid-semester break".

The failure was contributed to by: CLV's failure to fix a staff shortage arising from illness, injury and parental leave; and CLV leaving a key pastoral care position vacant from June until mid-August.

'LOOSE' RULE TO NOTIFY ABSENCES

One of the Village Rules requests residents notify CLV if they expect to be absent from their room for more than 48 hours, to leave an emergency contact number and to inform CLV if they are kept away from the village for any reason.

Toogood found the rule was only loosely observed at Sonoda.

Close to each study break or holiday weekends, RAs were to ask the residents in their key groups to notify them by electronic means if they would be away or stay in the village.

"Not all students comply with the request and there is no follow-up if a resident does not provide the information. Mason did not provide any such information."

CLV did not organise any room inspections at Sonoda during the mid-semester break.

"That combination of factors meant that CLV did not know whether Mason was expected to be residing in, or absent from, his room between 24 August and 6 September 2019, and had no plans to find out."

No-one, not Pendrous nor anyone else, raised concerns about his welfare with the university or CLV at any time before his body was discovered.

Toogood made several recommendations, including reviewing the number of residential assistants, installing a village manager on site during the day and reviewing CLV's welfare checks procedure.

WHO WAS MASON PENDROUS?

Pendrous, whose mother died when he was 14, had a close relationship with his stepfather, Anthony Holland. He maintained close and regular contact with his father, Steve Pendrous, particularly in recent years, and usually spent a week or so with Steve Pendrous and his partner during school holidays.

Mason Pendrous attended Scots College in Miramar, Wellington from 2014 to 2018, initially as a day boy and then as a boarder for three years from 2016.

He was an active member of his school community, including being a member of the rowing squad as well as having a leadership role in his school house in 2018.

Holland said he was "socially active" at school, had good friends, and participated in sports such as badminton and shooting.

According to Canterbury University students who attended Scots College, Pendrous had a "quiet, independent personality", with a quirky sense of humour. One described him as "a tall silent giant".

A close friend said he was easy to get on with and good company, but acknowledged he was often slow to respond to attempts to contact him.

In his last year or so at school, Pendrous was known to spend his lunchtimes, and free time after school or in the evening, playing games on his computer.

UNIVERSITY LIFE

Pendrous arrived at the Sonoda Village campus on February 13. Although he was known to be the resident of room 209 in the Hinoki building, he was rarely seen in his flat, the village or on the university campus after the first few weeks of the academic year.

He did not eat meals in the Sonoda dining room located in the Hinoki building, directly below his flat, or in the university hall dining room.

On May 8, Pendrous met with two student care staff employed by CLV at his room, when they handed him a new swipe card for his building and flat. He seemed to be in good spirits.

Between April 5 and May 12, Pendrous ignored efforts by university staff to contact him with offers to help him with his studies or in any other way.

By the beginning of June, he had disengaged completely from his studies and continued to ignore emails from university staff.

From mid-June he was not seen or heard by his flatmates, who assumed he was away.

Evidence of his laptop being logged into the university's wifi system every day, and the volume of data downloaded and uploaded, revealed he did not leave the campus, except for a few short trips, between February 13 and August 26, the last day he used the wifi.

From early June 2019, the teenager confined himself to his room, engaging in high levels of computer activity, particularly during July and August. His internet movements revealed he was usually online overnight until the early hours of the morning, and often until daybreak, and that he would then sleep until the afternoon.

CLV RESTRUCTURING

In late 2017, CLV reorganised its student care services. It also took on three more Canterbury halls.

Before 2018, the office area at Sonoda was open and usually manned by CLV staff from 8.30am to 4.30pm on weekdays. CLV said this was "labour intensive" and "costly".

As part of its proposal for change, CLV said 70 per cent of inquiries at the office could be avoided through "process improvements and automation".

Changes made in 2017-18 abolished community manager roles at Ilam, Sonoda and Uni Hall. A new position of community development manager was created.

CLV said its intention was to separate the "business" functions "so that there was more dedicated delivery of pastoral care". CLV said the "community team" expanded from nine to 12 full-time equivalent employees.

UC was informed and consulted in late 2017. It told CLV it agreed broadly with the proposed changes.

That was based on CLV's assurances it would not compromise resident service levels nor customer service.

However, Toogood found the changes had a real impact on pastoral care for first-year residents, in particular the office closure.

Although CLV pastoral care managers visited Sonoda as needed, they had responsibilities for about 1800 residents in seven villages – about 650 to 700 of them first-year students.

It would be "wholly unrealistic" they would be get to know students well enough to monitor their wellbeing.

At Sonoda, RAs provided the the only regular, frontline pastoral oversight. They engaged with students only when students sought or responded to engagement. "That is consistent with CLV's reactive rather than proactive approach."

A student needing support had to walk 12 minutes to the CLV office at Ilam to speak to someone they had no relationship with, Toogood said.

While it could be argued staff were available, it did not reflect the needs of first-year students.

Toogood said CLV was considering reinstating staff at the Sonoda office during the day, though that would have made no difference to Pendrous, who had "no inclination" to contact staff.

"But the regular presence on site of a trained employee whose duties included getting to know all of the residents personally, and who was provided with relevant information that might have raised flags about their wellbeing, would likely have led to more frequent interaction with Mason, whether he welcomed it or not."

CLV recognised that its reliance on concerns being raised about a resident meant there was a delay in discovering Pendrous' body.

"While it is willing and open to learn from this event, it remains cautious about intruding too far into the freedoms and independence of the young adults that it accommodates and is mindful not to [allow] ... unreasonable interference with their privacy."

CLV told Toogood a weekly roll call or check-up would not be workable, and said the residents had busy lives and could not be relied upon to attend.

STUDENTS SPENDING MORE TIME IN THEIR ROOMS

Toogood said a common theme in discussions with students and staff at UC and CLV was increasing numbers of students spending increasing amounts of time online from within the privacy of their rooms.

Toogood believed the prevalence of students not sharing the physical company of their friends or other students, or not engaging face-to-face with their teachers and other university staff, was in part at least, to be a reflection of the increasing availability of online tuition.

He said it was "strongly arguable" that ensuring reasonable access to services that support student learning and their wellbeing involved more than simply responding to a student's request for assistance, sending an email or message containing student care contacts and other information when a student is underperforming academically.

"Mason made choices that isolated himself from other students and from university and CLV staff; he would not have been alone in making them. But society is disadvantaged if young people are not assisted to make better choices or helped to address and remedy the consequences of poor choices that have been made."

Sonoda is no longer offered as accommodation for first-year students.

RECOMMENDATIONS

Toogood's recommended the university and CLV consider changes including:

- Make pastoral care and qualified residential staff numbers part of the accommodation agreement between the university and CLV.

- Villages for first-year students should have a suitably-trained staff member, not an RA, on site on weekdays, and for four hours a day on weekends.

- Regular welfare checks for each resident's room without cause, possibly by cleaning staff and/or RAs.

- Having RAs responsible for 25 to 30 students each

- Face-to-face contact between RAs and each member of their key groups at least once a fortnight.

- Require residents to notify the village manager of any lengthy planned absences, including dates, and enforce the rule

- Give CLV the grades of all of its residents that are at or below an agreed level.

- Document first-year students of concern, meal data, and academic engagement and results in university and CLV internal systems.

- Create criteria for contacting a resident's parent or guardian about their welfare.