Port Otago will review safety features around its wharves following a recommendation from the coroner's office after a young Dunedin man drowned below the city's Fryatt St Wharf last July.
Southern region coroner David Crerar has just publicly released his formal findings on the death of Regan McCormack (20).
He found Mr McCormack fell into the harbour for reasons that remained unclear, was overcome by the cold water, and possibly the shock of the fall, and drowned.
The surveying student had been at a party earlier that night, was described by friends as being very drunk and refused rides home.
He was possibly walking in the direction of his mother's home in Waverley when he somehow ended up in Otago Harbour.
Mr Crerar said while he could not rule out the possibility there was an assault which resulted in Mr McCormack, whose watch was missing, ending up in the sea, he did not treat that as being any more than a possibility, and in light of other evidence available, an unlikely possibility.
It was not totally clear why he had gone on to the wharf - he may have been looking for a private place to urinate.
His bladder was full at autopsy.
It was because of the lack of clarity, he specifically left open in his finding the circumstances of the death as they applied to Mr McCormack's actions between the time he was last seen and the time he entered the water, Mr Crerar said.
Mr McCormack's body was located at the bottom of an egress (exit) ladder to the Fryatt St wharf, which the coroner believed would be difficult to climb for anyone but a relatively fit, young, sober person, not compromised by a fall and the effects of cold water.
He recommended that Port Otago - which he emphasised was not responsible in any way for Mr McCormack's death - investigate methods by which more convenient access could be obtained by people who found themselves in the water, for whatever reason, and needed to get out.
He also recommended it consider installing safety lighting at egresses and supplying a life-rope and ring at the Fryatt St wharf.
Port Otago chief executive Geoff Plunket said Mr McCormack's death was a tragedy.
There were safety features dotted around all the company's wharves, but it would conduct an internal review and report back to the coroner.
Some areas of the harbour were used regularly by many people without problems, and the company needed to weigh up the provision of greater safety features, and possibly thereby less access, with the desire from the public to access and use the area recreationally, which was something the company wished to encourage, he said.
Mr Plunket said he had already written to the coroner seeking more information.
When contacted last night, Mr McCormack's father said he had no comment on the coroner's report.
He would continue his own investigation into what happened to his son, he said.