Key findings from inquest into UVic student’s on-campus death

Sidney McIntyre-Starko, a proficient dancer, died after accidentally overdosing last January. Photo: sidneyshouldbehere.ca

During the three-week-long BC Coroner Service (BCCS) inquest, a jury of five heard from 33 witnesses to understand the events that led to 18-year-old Sidney McIntyre-Starko’s death in January 2024.

McIntyre-Starko died from lack of oxygen, leading to cardiac arrest, after consuming what she thought was cocaine, for the first time, with two friends in their UVic dorm. Within minutes of consuming the illicit drug—which was laced with a fatal dose of fentanyl—McIntyre-Starko and one other student collapsed and began seizing. Security was called, and the third student who consumed the substance called 911. Several missteps, a lack of protocol for overdoses, and miscommunication left McIntyre-Starko waiting 13 minutes for life-saving naloxone and 15 minutes for CPR. Her heart was restarted at the scene, but she died three days later at the hospital.

An independent review of McIntyre-Starko’s death—led by former Abbotsford Police chief Bob Rich and released in April—found that it was preventable. Rich was hired by UVic to conduct the review and made 18 recommendations for the university to implement to prevent future deaths.

The purpose of the BCCS inquest was not to place blame for the death, but to determine the facts of the night’s events and make recommendations to prevent a similar death from occurring. The jury for the inquest determined the death was accidental and provided 10 recommendations to UVic, the province, and BC Emergency Health Services.

‘Like a Scarface movie’: drugs obtained in an unusual manner

A student and friend of McIntrye-Starko, identified as Student 1, said she found a box on a downtown Victoria street filled with bottles of coolers. She brought the box back to her UVic dorm with plans for her and her friends to drink the coolers on the weekend.

Another student, Student 2, testified that she and McIntrye-Starko had found a small glass vial filled with a grey-white powder in the cooler box. Student 2, McIntyre-Starko, and another student, Student 3, decided to try the powder before planning to watch a movie in their pajamas on a Tuesday night. Student 2 testified that she wasn’t thinking of the risks when they put the powder on the bathroom counter and snorted it through a straw.

Saanich Police Const. Ben Scoones, who is a drug expert for the department, says the story of finding the drugs by chance is possible, but not likely.

He said it’s uncommon to find street drugs in Victoria in a glass vial, explaining it looked like something from a movie, à la Scarface. He believes the drugs were purchased and may have come in tin foil or plastic before being put into the vial for a “cooler look.” The three students who testified, however, gave the same version of events.

Differing testimonies from security and students

During Rich’s review and the BCCS inquest, the two security guards who attended the call said that a crowd formed in the hallway and the room where Sidney and Student 3 were seizing, making it difficult to navigate the emergency. They also said the lights were dim, and it was hard to see whether the women were turning blue (a sign of asphyxiation). But student witnesses testified that this wasn’t the case.

The three students who testified said there was no crowd, the hallway was silent, and all three said the two seizing women were turning blue. One student said she didn’t point out the blue hue to security, assuming they were trained to identify that.

When Student 2 called 911, she mentioned that the women looked blue, but was spoken over by the 911 call taker who didn’t appear to hear the comment.

Security guard misinformed about naloxone

The security guards were carrying naloxone, which can reverse opioid overdoses, but said their training advised them not to use it unless an overdose was confirmed.

It became clear during the inquiry that one guard, Nikolas Murphy, was misinformed about the safety of naloxone (it can be used without risk, even if someone isn’t overdosing). Murphy said he believed it to be a new drug that hasn’t been studied enough. Naloxone has been approved to treat overdoses since the 1970s.

The second security guard on duty that night, Ben Watson, said he thought it was strange that two people would be seizing at the same time, but deferred to Murphy, who had more experience as a security guard.

Jessica Maclean, UVic’s director of campus security, said the guards did what they were trained to do that night, and protocols at the school have since changed. The school hired a new CPR trainer to work with security, created unique addresses for campus buildings, and expanded radio communications between security and emergency services in response to McIntyre-Starko’s death.

BC 911 software is not quick enough

Across Canada, 911 call takers use a system created by US company, Priority Dispatch. A top US doctor, Michael Kurz, head of emergency medicine at the University of Chicago, testified that the system takes too much time, wasting the handful of minutes needed to get to a patient who isn’t breathing.

Call takers aren’t typically medically trained. When speaking to callers, they ask a series of questions, entering the answers into the system, which then determines the emergency and type of ambulance needed.

The 911 call taker handling McIntyre-Starko’s emergency focused only on the seizures, which provides different instructions for treatment, including no chest compressions. It wasn’t until 11 minutes into the call that she asked security if drugs were involved.

Dr. Caroline McIntyre, mother of McIntyre-Starko and an ER doctor, testified that chest compressions could have kept her daughter alive while she waited for naloxone.

“This inquest was mostly held because my daughter was left for 15 minutes to die when 911 was called and when campus security was sitting there with Narcan in their pocket,” she said while testifying.

McIntyre said she spoke with her children about the risks of drugs, having seen the opioid crisis first-hand at work, but said she wishes she had spent more time teaching her daughter about naloxone. She never had evidence to believe her daughter or her friends used illicit drugs.

Kurz says he’s advocated for a “no, no, go” system for 911 call takers. Two questions would be asked: Is the person conscious? And are they breathing? If the answer to both is no, high-level emergency paramedics should be sent.

The Priority Dispatch system has not adopted this, preventing any municipality or province from implementing “no, no, go” for now.

BC ambulance changing protocols

It took over three minutes for the 911 call taker to determine the location of the Arthur Currie dorm at UVic. The provincial map the BC Ambulance Service (BCAS) uses when answering calls did not include the building, and there were no individual addresses on campus at the time.

The BCAS chief operating officer, Jennie Helmer, says the agency is looking into ways to prevent a similar time lag from occurring. The agency is considering a timer that ensures the call taker is aware of how much time has passed once they begin looking for an address.

Helmer also says an internal review committee has recommended that calls for seizures be upgraded to the highest level of response, up from the second-highest.

Starting next month, call takers will be allowed to ask whether drugs were consumed. Previously, call takers without medical training were advised not to ask leading questions. They will also be able to recommend naloxone even if an overdose hasn’t been confirmed. These changes were all in response to McIntyre-Starko’s death.

Recommendations from the jury

On Thursday, after deliberating for two days, the jury released 10 recommendations to UVic, the province, and BC Emergency Health Services.

For the minister of education and child care:

• School districts in BC should implement instructions on CPR, AEDs, and nasal naloxone. Presentations on drug identification, effects, and risks in high schools should also be implemented
• High schools and post-secondary schools should offer in-person, compelling presentations about the drug crisis using real stories from survivors and/or family members

For the minister of post-secondary:

• Work with BC Emergency Health Services to make sure each building on post-secondary campuses has a unique address (something UVic has implemented)
• Provide scheduled work time for security officers to review training manuals, protocols, and best practices every semester, with completion of these reviews documented
• Direct campus security to connect the caller with 911 regardless of any other calls to 911 being made
• Conduct debriefings after serious incidents
• Require security officers to complete incident reports for serious incidents by the end of their shifts, with the director of campus security reviewing those reports every 48 hours
• Install surveillance cameras in public areas such as bus loops
• Create policies to clarify who is responsible for calling the emergency contact person for a student who is unconscious or in a serious medical emergency within one hour
• Maintain contact with a person who has received naloxone but not been taken to the hospital, checking in every 30 minutes over the next hour and a half
• Ensure that campus counsellors or mental-health support workers check in with students who witnessed events leading up to serious incidents such as the death of a student

For UVic:

• Create a mandatory in-person or online orientation for first-year students that goes over how to contact 911 and campus security, how to obtain and safely administer naloxone, and information on AEDs and drug testing services
• Give the same course to its campus security officers as part of their training
• Recommended course should emphasize to students that they will not face repercussions for accessing naloxone or drug testing

For BCEHS:

• Review its policies on obtaining identification and dispatch technology upgrades
• Incorporate an internal timer to monitor how long it takes to obtain the location where an incident occurred

For the International Academy of Emergency Dispatch:

• Consider updating its system so that when multiple unconscious patients are reported, it generates an immediate response and a follow-up question regarding the possibility of drugs being involved.

McIntryre-Starko’s parents say they were pleased with the jury's recommendations and with their diligence in the inquiry.

“I think the recommendations they made were excellent, and I can see how they will be very beneficial going forward,” Ken Starko said.

“Oliver, Caroline, and I would like to thank all of the people who loved and supported Sidney in her short life and all of the people who continue to hold us up,” Starko said.