University of Utah failed to recognize student Zhifan Dong was in danger before she was killed, documents show

The University of Utah knew that student Zhifan Dong felt she was in danger.

Both Dong and her roommate spoke to U. housing staff several times, alleging that Dong’s boyfriend had hit her after she broke up with him and reporting that she was scared about what he would do next.

But documents released by the school Tuesday show that housing employees — once again — failed to recognize clear signs of intimate partner violence and the potential that it could escalate, even after Dong told them she had gotten a protective order against the man who lived one floor above her in the same dorm.

And like student-athlete Lauren McCluskey three years before, Dong was killed by the man she had warned the university about.

After McCluskey was shot to death on campus by a man she had dated, the university pledged to fix gaps in training and communication, specifically among housing staff and campus police, that had been exposed by the mishandling of her case. But the records about Dong’s experience — and a recent audit from the state — show those flaws persisted and contributed to another tragic death.

Employees in the dorms and elsewhere repeatedly mixed up the name of 19-year-old Dong and her former boyfriend, also an international student from China, in their reports. They also repeatedly called the phone number of another student with the same name as the man she was reporting, 26-year-old Haoyu Wang.

And dorm staff waited weeks to relay her concerns to campus police, not making the call until after she had been reported missing, with her roommate saying she had not seen Dong for about 10 days.

Shortly after that — about a month after she first reached out to the U. for help — Dong was killed on Feb. 11 at a downtown Salt Lake City motel, police say. Wang has been charged with homicide and is currently in jail. He has a competency hearing scheduled for next month.

The U. took responsibility for its mistakes Tuesday, saying in a statement: “The university acknowledges shortcomings in its response to this complex situation, including insufficient and unprofessional communications, a gap in the training of housing workers, and a delay in notifying university police of indications of domestic violence.”

The school has since taken disciplinary action against three housing employees and two have resigned.

But the case has brought renewed criticism on the flagship school for ignoring problems, waiting months to release records and endangering students in its housing, right as it has been pushing for more young adults to live on campus.

“We trusted the University of Utah with our daughter’s safety, and they betrayed that trust,” said Dong’s parents, Junfang Shen and Mingsheng Dong, in a statement provided by their attorneys to The Salt Lake Tribune. It was translated from Chinese. “They knew Zhifan was in serious danger but failed to protect her when she needed it the most. We do not want her death to be in vain.”

Dong was their only child, an artist with dreams of working after graduation in Silicon Valley, where she wanted to buy a big house with a garden and small farm.

McCluskey’s mom, Jill McCluskey, extended her sympathies to the family and said she regrets that the U. has not made the improvements that it promised to put in place after her daughter’s death.

“They can’t afford to fail,” she said, “because it means we lost someone’s daughter, roommate and friend.”

The Tribune had been fighting for some records related to Dong’s case for months, and won an appeal in June to access the campus police report in the case. The U. had until July 28 to provide that to The Tribune, but instead publicly released the trove of documents.

U. President Taylor Randall released a statement Tuesday, as well, saying: “As a public university, the U. has a responsibility to serve the public interest and to respect the public’s right to know, in good times or in bad. Of course, it’s always a challenge to be fully transparent while still respecting the privacy of students, faculty, staff and their families. But let me be clear: transparency shines a bright spotlight on our actions. Only by seeing can we improve.”

[Read more: Read University of Utah president’s full statement on mistakes in Zhifan Dong’s case and the released documents]

The documents released to the school community and media, though, show repeated missteps and ineffective reform.

An initial conversation with housing staff

The first report Dong made about her concerns was to Salt Lake City police on Jan. 12.

Dong said she and Wang got in a fight at a downtown hotel where they were staying. He got mad, she said, when she broke up with him, according to a police report obtained from the department by The Tribune through a public records request.

Police noted in the report that a large bump was visible on Dong’s head and that Wang had a swollen hand. They arrested Wang and charged him with domestic violence related assault.

A day later, Dong again called police due to Wang’s alleged behavior, court documents note. He had been released from jail and was at the hotel; she was gone when officers arrived. Police confirmed this follow-up call for service for the first time to The Tribune on Tuesday.

Dong told a resident advisor with the U.’s Housing and Residential Education office about the altercation two days later, with a written statement. Her roommate, Bailey McGartland, helped her, according to reporting in the campus newspaper The Daily Utah Chronicle.

Dong wrote: “He wanted me to leave the room so I began to pack my bags.” Then, she recounted, he turned off the lights. She said he held her around her neck and pinned her arms. She scratched him to get him to let her go; then, she said, he began to hit her.

She ran to the hotel’s front desk, where staff helped her call police, she recalled to a U. housing employee.

At that point, Dong said she was worried about Wang — concerned he might try to harm himself. The report also notes he made other “endangering” threats to Dong.

But she asked them to check on him at the dorm, Sage Point, which sits on upper campus near the foothills.

A resident director said she would take over from there and called an area housing coordinator. They both tried to contact Wang but could not reach him at the phone number he had listed in the U.’s system, which was a nonworking number. Dong provided a different number. He still didn’t pick up.

The resident director told Dong, according to the report, that there wasn’t much else she could do. She gave Dong the phone number for the on-call dorm staff and university police, in case anything further happened.

The housing report was submitted with a note: “No further action was needed.”

A mental health staffer with the Huntsman Mental Health Institute on campus also responded that night — at the request of the resident director — but that person came to the same conclusion, which they described in an email on Jan. 15. The mental health staffer couldn’t reach Wang, either, and told Dong it was up to her to follow up with the housing resident outreach coordinator.

But the university says all of the housing staff who responded — seven employees in total, including two student workers — should have escalated the situation to a “welfare” response instead of “wellness.” According to their training, that involves any incident where a student is believed to be at risk for domestic violence or suicidal ideation, both of which applied with Dong’s report.

They should have recognized that what she was describing was a red flag for intimate partner violence, noticing these signs: her fear, her protective order, Wang lashing out at her physically for breaking up with him, and his threats to harm her and himself.

“When someone comes forward with allegations of domestic [violence], the appropriate response is to start by believing the victim. Starting from this position, any lack of recognition of abuse signs becomes secondary,” said Jen Campbell, executive director of the Utah Domestic Violence Coalition, because the report should be enough to spur action. “It takes strength and courage to bring allegations of abuse forward, especially to anyone in authority.”

That “welfare” approach also would have called for police to immediately respond, according to the U.’s statement Tuesday. And, under the protocol, efforts would not have stopped until contact was made with both students. But that didn’t happen.

Staff also were supposed to report to several other offices on campus, including the Office of Equal Opportunity and Affirmative Action, the Office of the Dean of Students and the Behavioral Intervention Team.

“In this case, key details were overlooked and staff failed to make connections with other parts of campus that could have accelerated the university’s ability to gather additional information and respond more urgently,” said Lori McDonald, vice president for student affairs, in a statement. “This is unacceptable and will not be tolerated.”

Campbell added: “When victims request help, there is no room for silos or a lack of open communication, especially when the victim is mid-crisis.”

What records show happened over the next month

But after that initial report, documents show, mistakes and the failure to communicate with police continued for weeks.

The U. released a timeline of events, as well as redacted documents logging housing staff’s interactions — or missed interactions — with both Dong and Wang, and the police report filed when Dong was later reported missing. Her disappearance finally prompted campus police involvement.

The university had argued that it shouldn’t have to release the initial campus police report because it had been instructed not to by the Salt Lake County District Attorney’s Office as the criminal investigation with Wang proceeded.

But that report is considered a public document under Utah law. The U. said Tuesday it was releasing all of the documents “in the best interest of transparency now.” The disclosure comes five months after Dong’s death.

Following Dong’s first report to dorm staff, over the next few weeks, a housing resident outreach coordinator tried reaching out to both Dong and Wang several times, starting on Jan. 18. That person continued to try to reach Wang, though, but using the number that didn’t work, instead of the one that Dong provided.

On Jan. 24, the staffer decided to try to visit both students in person. Dong wasn’t home. But Wang opened the door at his dorm and told the employee he was doing better and volunteered that he had a counseling appointment scheduled for that day. He said he had dealt with depression for most of his life, according to the reports.

By Jan. 31, though, the university still couldn’t find Dong. And she wasn’t responding to emails, calls or texts. Again, staff visited her room, and she wasn’t there.

A roommate said she hadn’t seen Dong for “a while.” McGartland told The Chronicle said that wasn’t entirely unusual, because Dong typically spent a lot of time at Wang’s suite upstairs. But she was worried.

Housing staff tried to call Wang again. This time they called another student by the same name.

“[They] do not know there are two students with the same name and they have spoken to the wrong student,” the U. stated in its release.

At the same time, several people reported concerns about Dong’s welfare to the U. One of her instructors in the Utah Global program, which helps immerse first-year international students in the academic and cultural life of the university, told their supervisor that she hadn’t been in class for an extended period.

On Feb. 6, McGartland reported concerns about Dong to the front desk of the residence halls, a report said. She said she had not seen Dong for about 10 days. She said a friend of hers had seen Dong on campus with Wang, and Dong was crying; the friend, according to McGartland’s Chronicle interview, reported that to campus police’s nonemergency line. But U. spokesperson Chris Nelson said the school has no record of that.

Dong did respond to a text message from housing staff that day, saying she was “OK,” but dealing with a family matter. She declined any help from them, saying, “No, thank you,” according to screenshots provided by the U.

On Feb. 7, staff from Utah Global asked for a wellness check on Dong. At that point, the U. checked for the last time she had used her student ID card to get into her dorm building. They discovered she hadn’t done so since Jan. 28.

Housing staff hadn’t checked that data on Dong until then, another misstep noted by administration, which said that should have raised concern sooner — that possibly Dong was being held against her will by Wang or hiding from him. Wang’s last swipe to enter the building was Jan. 25.

At one point, staff described him as no longer being in the Utah Global program. But he was, Nelson confirmed. They also didn’t realize until after Dong’s first contact that Wang wasn’t taking enough credits to keep his visa to be in the United States.

Nelson said those were more communication mistakes that complicated the case.

Those, too, are similar to McCluskey’s case. Campus police originally said her attacker was living in a halfway house; he was not.

Police get involved and concern about ‘unprofessional communications’

On Feb. 8, the U.’s housing office first contacted U. police, according to the records. They called to place a missing person’s report on Dong.

At the same time, Utah Global and the Behavioral Intervention Team at the U. did the same, as more people alerted them to concerns about Dong and inaction to their pleas to check on her. Housing later contacted both offices for help in reaching Dong’s parents.

Dorm staff also realized that day, according to the documents, that some of them had been calling the wrong number, this time for Dong, after someone else answered and informed them of the mistake.

From there, the U. says that officers — and other offices, like OEO — did all they could to step in. But the university also acknowledges “unprofessional communications” between employees in the dean of students’ office and Utah Global about the case. Those texts are included by screenshots in the released documents.

At one point, staff referred to the two as “Dang” and “Wong.” After talking with Dong’s mom on Feb. 9, they also mocked her for not understanding the situation as they saw it.

One employee wrote: “Kinda sad how the whole concept of domestic violence barely register [sic] with the Mom.” They then sent the face palm emoji and added, “But what can we do.”

Dong’s mom had said she had talked to her daughter earlier that day and her daughter told her she just needed some rest. She said Dong told her that she would return to campus by Feb. 11.

In another exchange, one staffer asked: “What’s this about a missing student?” The replies are redacted. But one has a laughing reaction visible.

Nelson said: “We expect the highest levels of communication from our [staff] when working on cases.”

He added it’s “nothing compared to the crudeness” that occurred in McCluskey’s case. During that investigation, an officer had showed off nude photos of the student that she had sent him as evidence in her extortion case.

U. police officers were able to connect with Dong via FaceTime. She was at a hotel and walked around the room showing them that she was alone. An officer wrote in a report: “No visible injuries were seen on the female. The female refused to identify her location to police.”

They intended to keep the missing person alert on her, though, until they could meet with her in person and verify her safety. They wrote in their report that she was a previous domestic violence victim and “may be in danger.”

Detectives pinged her cell phone to a 1-mile radius downtown. They visited seven hotels in that area and could not find anywhere Dong was registered to stay; the motel where her body was later found was one of those locations checked.

But Nelson said university police checked with the clerk there, giving the names of both students and showing photos. Police were told Dong and Wang were not there, he said.

At this time, a U. police staff member also reached out to Salt Lake City police about the Jan. 12 domestic violence incident. They asked the victim advocate there if she was working with Dong. According to the campus police report, the victim advocate said they did not know who Dong was.

The U. also said that Salt Lake City police never alerted them to the protective order that Dong had against Wang. After McCluskey’s death, the two police departments were asked by state leaders to share information about student cases, since their jurisdiction overlaps.

The U. said it is switching its reporting system to the same as Salt Lake City to help with that communication.

Salt Lake City spokesperson Brent Weisberg said officers did provide Dong with a domestic violence resource card at the time of the Jan. 12 assault; they also alerted her, he said, when Wang was going to be released from jail.

The victim advocate at the Salt Lake City department twice attempted to call Dong, on Jan. 20 — more than a week after the alleged assault — and again on Feb. 10, Weisberg said. They also mailed a letter to her last known address, but that was returned. They were unable to make contact.

He said the department is not required by law to alert other agencies about “domestic violence or intimate partner arrests or protective orders.” It’s not clear if the department knew Dong and Wang were students.

The U.’s police department did try to communicate with both Dong and Wang, as well as their parents. Though, again, in trying to contact Wang’s father, they had the email address for the father of the other student by the same name.

The director of the community services division had a brief text conversation with Dong, saying they could help with anything she needed. She responded, “OK, thank you.” The employee asked if she wanted any assistance, specifically, with the upcoming court hearing against Wang. She said, “Thank you, but I want to do that by myself.”

The day of Dong’s death and Wang’s arrest

Housing officials were also still texting with Dong. She told them she was resting and would meet with someone on Feb. 11 on campus to discuss what was happening. She died before that meeting was scheduled to occur.

Meanwhile, one of her roommates requested to leave their suite over the concerns.

On Feb. 9, housing staff also reached out to Wang — about a month after the protective order was signed — to say the court order meant he could no longer stay in the dorms, even though he hadn’t been there since Jan. 25 and housing staff knew about the protective order.

The U.’s release states: “The university is only made aware of protective orders when victim-survivors notify a staff or faculty member.”

Wang then called the housing staff member back and yelled at him. “Who is going to pay?” the staffer wrote that Wang asked him, recounting the exchange in an email. The staffer said he was confused, thinking Wang was concerned about paying for housing outside of the U.

“No, who is going to pay for my lost reputation when I am found innocent of being a domestic abuser?” Wang allegedly said. “The police are the ones who need to pay because they did not listen to me when I told them I did not harm anyone.”

The staffer then said Wang told him not to contact him again; the staffer told his bosses that he would not unless instructed otherwise.

Early in the morning on Feb. 11, with a message timestamped at 3:51 a.m., Wang sent an email to that same housing employee and told him that he and Dong had made a plan to die by suicide together.

He said he had ordered drugs on the internet. Wang said they both took those drugs, and Dong became unresponsive.

In the email, he said he injected her with a larger dose of drugs so she wouldn’t suffer. She then died.

The housing employee saw the email at 4:49 a.m. and called campus police.

Salt Lake City police, assisting University of Utah officers, arrived at the motel after pinging Dong’s cellphone location. Dong was found dead at a Quality Inn at 616 S. 200 West in a room that had been registered to Wang since Feb. 3. Wang was taken into custody.

“We remain saddened that we were unable to locate them in time,” said U. Chief Safety Officer Keith Squires in a statement Tuesday.

U. says it has taken action

The university says it has taken substantial action since Dong’s death to improve its procedures, particularly in its housing department.

It included in the documents the discipline letters to two staff members, sent on March 11. Those are described as a “final written warning notice.” The U. declined to provide the titles of the employees, but said none of them were students. They also declined to say whether the employees had been disciplined on the job before for previous violations.

One of the letters states: “Specifically, you failed to follow policy and procedures for mandatory reporting. This is counter to training you have received and to the established protocols within the department.”

The staffer was asked to do better in the future and to schedule a follow-up meeting for April to discuss progress.

A third dorm staff member was issued a “letter of expectation,” considered less strong than a “final written warning notice.”

All of the letters acknowledge the U.’s housing department has been under stress from dealing with COVID-19, as well as a dire staffing shortage.

Nelson said the residential education team had 11 open positions of 19 professional employee posts at the time of Dong’s death.

“There was significant turnover during the December break that we attribute to the ‘great resignation’ and the ongoing shortage of qualified workers,” he said.

Additionally, the former director of Housing and Residential Education, Barb Remsburg, had recently stepped down — unrelated to this case.

Still, the letters say that is not an excuse for poor performance. They say staff had been trained in July 2021 on mandatory reporting, in December 2021 on recognizing domestic violence and on mandatory reporting again in January — shortly before Dong came to them with concerns.

Nelson and the letters both acknowledge, though, that the training — much of which was instituted after McCluskey’s death — may not have been thorough enough.

The letters say, too, that the housing manual for employees doesn’t say which staff members should specifically report domestic violence to police or what domestic violence looks like. It also doesn’t distinguish well between a welfare and a wellness check or who should classify that.

“Our review of the recent tragedy demonstrated gaps in staff members’ understanding of how to identify and respond to issues of interpersonal violence and suicidal ideation,” the letter of expectation says.

Nelson said: “We thought the training was clear. And then when you have five employees who don’t react the way you’d think they’d react, we can see it was not. It wasn’t lack of training. It’s revising training to make sure it’s getting across what needs to be known.”

Housing Executive Director Sean Grube, hired in March, said all dorm staff will receive revamped training on emergency procedures for the upcoming school year, after a consultant reviewed the department and its manuals.

The school also said it is reducing the “hierarchy for reporting” in housing that may have led to confusion on who was supposed to act in an emergency. And it has hired a new staff member to review all cases for possible concerns.

It has also updated the system where student phone numbers are located and shared.

‘The same mistakes with the same tragic consequences’

Dong’s parents have retained the law firm of Parker & McConkie to represent them with any claims arising from the U.’s missteps. That same firm represented the family of McCluskey against the U. for similar failures to protect their daughter.

The McCluskey family settled for $13.5 million.

“The University of Utah failed Zhifan and her family, allowing her to be needlessly killed by another student who was known to have violently assaulted her only weeks before,” said Brian Stewart, the attorney representing the parents in this case. “Especially after professing to have learned from Lauren McCluskey’s death, it is inexcusable that the university continues to make the same mistakes with the same tragic consequences.”

When asked about repeating those mistakes, Nelson acknowledged: “This comes down to the human factor and the training, quite honestly. And the training needs to be clearer. In this case, we thought the training was clear. For whatever reason, the employees didn’t react as they should have. It’s incredibly frustrating. And the consequences are extremely significant.”

After the murder of McCluskey in October 2018, an independent audit found that the U.’s on-campus housing department failed to contact university police when they learned about a threat to her safety.

McCluskey’s roommates had told housing officials that the man McCluskey had been dating talked about bringing a gun to the school and they were scared about his control over her. Those officials filed a report, but focused on whether housing rules were being broken rather than assessing her safety. They did not forward the report on to law enforcement.

In a statement that mirrors that same issues with Dong’s case, investigators said then: “Institutional structures at housing prevented an early attempt to intervene when Lauren’s friends reported that they believed she was in an unhealthy relationship. The information was passed up the chain of command, but decisions and responses were delayed.”

They advised: “The University should streamline reporting processes within housing.”

The U. said it made those fixes and listed several reforms in a news release Tuesday that have been made since McCluskey’s death.

But also earlier this year — roughly three years after McCluskey’s murder — state auditors released a new review saying those same issues with housing on campus had still not been addressed. A student living in the dorms at the U. reported that a roommate had threatened them with a weapon. The student reported that to housing officials. But campus police were not told about the threat until 24 hours later.

Asked about those concerns as the U.’s President Randall pushes for more on-campus student housing and for alumni to take in students, Nelson said it is a “legitimate question.”

“We’re releasing this information so students know what happened, know we’ve taken action and know that we are constantly improving,” he said.

Dong’s parents say those changes should have already happened, and they lost their daughter because of the U.’s inaction.

“We can’t believe it, and we don’t want to believe this fact,” they said. “We cry and are choked up over the pictures of our daughter, her lovely smiling face and familiar voice replays in our minds like a movie over and over again.”

Correction: 5:40 p.m. July 19: The story has been updated to reflect that the unprofessional communication was between staffers in the dean of students’ office. A U. spokesperson originally identified the exchange as between police officers. A description of a planned meeting with Dong has been removed because the context is unclear in the documents. 8 p.m. July 20: This story was updated again as the university further corrected its information, saying an additional employee was included in the initial response and additional employees were involved in the unprofessional communication.