The jury in a British Columbia coroner’s inquest into the overdose death of a University of Victoria student has recommended a raft of measures for government, schools and B.C.’s emergency dispatch system.
Key among the five-person jury’s recommendations released late Thursday morning were boosting education around safe drug use, making sure campus buildings were clearly addressed and stocked with emergency equipment, and updating protocols for campus security and B.C. Ambulance 911 call-takers.
Sidney McIntyre-Starko, 18, died in January 2024 after snorting fentanyl in her UVic student residence with two dorm-mates.
The coroner’s inquest into her death, which began May 5, heard that despite two of the three students falling unconscious and turning blue, campus security officers with first aid and naloxone training didn’t administer the opioid-reversing drug until nine minutes after they arrived, and didn’t start CPR for another three minutes after that.
The 911 call also faced scrutiny during the inquest, starting with the B.C. Ambulance call-taker taking the first 3 ½ minutes of the emergency call to determine the location of the Sir Arthur Currie student residence on campus.
A coroner’s inquest into the overdose death of 18-year-old UVic student Sidney McIntyre-Starko released its findings Thursday. The inquest jury is calling for action at numerous levels, from government ministries and the university to 911 dispatchers. Karin Larsen has the details.
“I just don’t see that building on my map,” said the B.C. Ambulance 911 operator during the call. “Maybe it’s one of the ones not labelled?” The Sir Arthur Currie student residence opened in 1967, according to the UVic website.
Among the many recommendations to the minister of post-secondary education is for all buildings on all campuses to have unique civic addresses that are clearly labelled on the building itself and on maps.
Lifesaving first aid was also delayed because the student who called 911 did not immediately reveal to the 911 operator or to campus security that she and her friends had taken drugs. That student told the inquest it was because she was afraid of getting in trouble.
The inquest also heard testimony about the software used by the 911 operator. With the two unconscious students reported as turning blue and having seizures, the software put the 911 operator into the system’s seizure protocol, which directed the 911 operator to ask if the unconscious students were pregnant or had brain tumours, among other conditions.
A recommendation to the International Academy of Emergency Dispatch, which controls the proprietary software known as Medical Priority Dispatch Systems, is to update the software to react to reports of multiple unconscious patients by generating an immediate priority response, while directing the operator to ask a follow-up question regarding possible drug consumption.
Kenton Starko, Sidney’s father, praised the work of the jury at the conclusion of the inquest.
“I think a lot of positive recommendations were made,” he said. “They made the best recommendations they could with the information they had.”
The lawyer for the McIntyre-Starko family said the overriding question coming out of the inquest is how to make change to help future victims of B.C.’s overdose crisis.
“This was a preventable death,” said Anthony Vecchio. “The issue of prevention starts with UVic, and a girl who was left for 15 minutes before she had CPR, 12 minutes before she was given naloxone.”
The B.C. Coroners Service says unregulated drug toxicity is the leading cause of death in the province for persons aged 10 to 59, accounting for more deaths than homicides, suicides, accidents and natural causes combined.
Since B.C. declared toxic drugs a public health emergency in 2016, over 16,000 people have died of overdoses.
Coroners’ inquests do not assign blame but are public inquiries that aim to determine the circumstances surrounding a death.