'Not properly cared for': independent review of UVic student's death identifies failures

An hour after hanging up a FaceTime call with her mom last January, first-year UVic student Sidney McIntyre-Starko, 18, stopped by her friend Leah’s dorm room, clad in PJs and a hoodie from her dad, with plans to watch a movie with friends in the student lounge.

Shortly after entering the room, students in the dorm heard strange noises, followed by a bang. They found Leah lying in the doorway of her room and McIntyre-Starko on the floor inside—both of them unconscious.

The women, along with one other student, decided to try cocaine that night—a first foray into experimenting with street drugs for McIntyre-Starko. What the students didn’t seem to know was that roughly 80% of Victoria’s street-drug supply at the time was contaminated with enough fentanyl to cause an overdose.

McIntyre-Starko and Leah, also 18, were both overdosing on fentanyl-laced cocaine. Leah would survive, but McIntyre-Starko was unable to be revived and was placed on a hospital ventilator. Three days later, she was pronounced dead.

Her death sent shockwaves across not just UVic’s campus, but post-secondary institutions throughout the country.

An external review of the circumstances of her death was released yesterday, highlighting the failures of UVic, campus security, and community leaders.

Written by former Abbotsford police chief Bob Rich, the report offers an in-depth look at what went wrong that night and lays out 18 recommendations to try to prevent such deaths.

Security not prepared to handle overdoses

Two security officers on duty that evening received a report that two students were having seizures in the Sir Arthur Currie student dorm. They weren’t informed that the students had taken drugs and that the seizures were a symptom of an overdose.

The officers had been trained in handling emergencies and had attended multiple calls for people described as having a seizure. But neither had ever responded to an opioid overdose.

It wasn’t clear to them why the students were seizing, according to the report. When they asked whether the students had consumed drugs, other students were hesitant to confirm. They eventually heard from a student that the women might have taken something, and they administered overdose-reversing naloxone—nine minutes after arrival. McIntyre-Starko had gone into cardiac arrest, her pulse undetectable, by the time CPR was administered. The security officers did not have oxygen equipment on them—something UVic security carried until Feb. 2023. A person can survive for up to five minutes without oxygen before permanent brain damage sets in.

Community leaders (CLs) in the UVic dorms—commonly known as residence advisers, or RAs—were also unequipped to handle overdoses. In their two-week training prior to the start of the school year, there was no instruction on overdoses and naloxone administration. They were advised not to give first aid to students. CLs who spoke to Rich said they felt unprepared to handle medical crises. Last August was the first time CLs were trained to use naloxone—though they were still told administering it was not part of their jobs.

Dispatchers at 911 were not made aware that the students had consumed drugs—the person who called was the third student to have consumed the cocaine with McIntyre-Starko and Leah that night. She was high when speaking with dispatch and lied about her and her friends’ drug consumption. It wasn't until 13 minutes into the call that she made them aware that the two seizing students had taken something, which affected the advice given by 911. The 911 dispatcher also did not provide instructions for how to properly check McIntyre-Starko's breathing.

The delay in both administering naloxone and CPR drew criticism from McIntryre-Starko’s parents, who demanded accountability from the school.

The parents, both scientists—McIntryre-Starko’s mother is an emergency physician and knows the treatment protocols for overdoses—conducted their own research on the events that night. Her father, Ken Starko, told the Vancouver Sun, “Our investigation has revealed systematic failures in the systems implemented by UVic and the province of BC. A student’s death was inevitable. It was only a matter of time.”

Rich's report says that at least four suspected overdoses had occurred on campus in the weeks between mid-December 2023 and the time of McIntyre-Starko's Jan. 23, 2024 death. Days before her fatal overdose, the school's campus security director had reached out to the safety manager to develop messaging on the uptick in overdoses. But the school did not have a clear process for approving urgent messaging of this nature—no such messaging had ever been put out before. The drafted message created before McIntyre-Starko's death made no mention that the overdoses and toxic drugs were on and near the UVic campus.

Sidney’s parents and other students left in the dark

UVic did not reach out to McIntryre-Starko’s parents when she was rushed to Royal Jubilee Hospital—nobody in an official role did. They found out that she was at the hospital through their son, a fourth-year UVic student, who had received a text from another student.

The hospital had no record of McIntryre-Starko's admittance since she hadn't arrived with ID. Her brother spent hours trying to locate her, with Jubilee staff initially insisting she wasn't there. They eventually bought him to see her, warning she was in "serious condition."

The two other students who consumed the drugs were left vomiting in their dorm to be taken care of by fellow students. They eventually went to the hospital, where they were checked and given naloxone kits. They were accompanied home by other students, who were still caring for them.

"No one from the university attended the hospital on January 23rd," reads the report. "No staff member was tasked with caring for [the other students who overdosed] to ensure that that they did not relapse. No one other than Campus Security Officers and the 2nd floor Community Leader spoke with the other students present on the 3rd floor."

Rich concluded that “the response by the university to this medical crisis that night was not well-coordinated or thought out. Sidney, her family, the other students who overdosed, and the students who tried to help were not properly cared for that night.”

How UVic responded

The morning after McIntyre-Starko was sent to the hospital, UVic officials met to work on a response plan. They discussed whether they should contact her parents about the incident, with some in the room arguing it was too late or that it was the hospital’s duty. They chose to have the director of student life at the school write a letter to the parents, which was then faxed to the hospital.

The officials also developed an email to send to students living on campus. In it, they wrote, “As you are aware, there is a concerning trend of unsafe drugs in BC.” There was no mention in the email that two students had just overdosed on campus. Another email was sent to the entire UVic community days later. Again, there was no mention of the recent overdoses or clarification that drugs in the UVic area were exceptionally toxic.

According to Rich’s report, UVic leadership often “worked in silos,” not collaborating or sharing vital information with one another. The report also noted the school’s inability to adapt to change.

Over a week after the overdoses occurred, McIntyre-Starko’s parents met with UVic president Kevin Hall and the associate vice-president of student affairs. Her parents grilled the two school officials with 37 questions.

“The president was not in the place to be able to answer the very specific questions that were asked,” Rich wrote in the report. “The meeting ended poorly.”

The report's recommendations

In his report, Rich calls for 18 recommendations for UVic to better prevent on-campus overdoses.

They include a shift in the school’s culture, improving cross-team communication, and notifying students when there are changes to street drug toxicity in the area. Additional recommendations include improved first aid training among staff, more focus on student safety, and changes in dealing with the media in these incidents.

“Like many tragic events, there were several points where, had the response been different, Sidney likely would not have died,” Rich wrote. “Once Sidney had overdosed on an opioid, the outcome of these factors led to Sidney not getting the respiratory support and/or naloxone she needed soon enough to save her life.”

Hall says the school has already made progress in improving its emergency protocols, including by commissioning Rich’s report, installing nasal naloxone kits across campus, and improving signage to help emergency responders navigate campus. The school began this year to post drug toxicity warnings on its news page.

Many of these changes are in response to new requirements from the province, made after McIntyre-Starko’s death. Post-secondary schools throughout Ontario and in other provinces have also made changes to their emergency plans and drug awareness campaigns in response to her death.

“We still have work to do,” Hall said in a statement. “This will take time, and we’re committed to the work ahead.”

A BC Coroners Service inquest into the death will take place later this month.