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UVic accused of ‘systematic failures’ after student dies from overdose

The parents of Sidney McIntyre-Starko say major mistakes were made the night the 18-year-old died

One Tuesday last January, after attending her first-year chemistry class, Sidney McIntyre-Starko texted her father looking for help with a physics question.

“Are you able to solve this? I’ve gotten all the other questions on this assignment, but I’m stuck here,” the University of Victoria science student messaged Ken Starko, an engineer.

It was 4:51 p.m.

Sidney, 18, then FaceTimed her mother, Vancouver emergency room physician Dr. Caroline McIntyre, at 5:07 p.m. She wanted her mom to pack a grey sweater for a family wedding they were to attend that weekend in Toronto.

“She was looking forward to the wedding, but was nervous to miss school on the Friday,” McIntyre recalled.

“She mentioned that she would not stay up late that night because she had an early lab or class in the morning.”

It would be their last conversation.

Five hours later, at 10:30 p.m., McIntyre and Starko received a frantic text from their son Oliver, a fourth-year UVic student, who had heard from his sister’s friend that Sidney had been rushed by ambulance to Royal Jubilee Hospital in critical condition.

“The doctor is saying that she took something with friends, some of them are here too,” Oliver wrote.

“She is on a ventilator, but the doctor says she is stable. They are about to move her to the ICU. I will be here with her.”

At 6:32 that evening, while dressed in her fuzzy grey pyjamas, Sidney had collapsed in a dorm room from fentanyl poisoning, and suffered a cardiac arrest soon after.

Starko and McIntyre struggled to absorb the news. To their knowledge, their daughter, who loved music, dance and Greek mythology, had never used illicit drugs before.

Too late to catch a ferry or plane from her Vancouver home, McIntyre stayed up all night on Jan. 23, making panicked phone calls to the hospital and Sidney’s friends to try to piece together what happened.

As a doctor at a large hospital, she was familiar with the toxic drug crisis, which the province declared a public health emergency in 2016. “I know that it is easy to reverse and treat an opioid overdose, but it has to be treated quickly before the brain suffers damage from lack of oxygen,” she said.

Sidney’s friend told the worried mother that 911 had been called quickly and first responders had provided first aid. That gave some hope to McIntyre and Starko, who was in France on business.

Opioid overdoses cause victims to stop breathing, but survival rates are high if there are people nearby to help. They can perform CPR until first responders arrive to take over, or administer the overdose-reversing medication naloxone, said Dr. Andrew Campbell, a Vancouver General Hospital emergency physician not involved in Sidney’s treatment.

“If you can get to someone within those first … six or seven minutes and give them the (naloxone) drug, they can have 100 per cent survival almost. It’s a very high success rate,” Campbell said.

“But time is really important.”

When Sidney’s mother arrived at the hospital in Victoria the next morning, she became skeptical whether her daughter had received prompt first aid: Sidney had severe brain damage due to a lack of oxygen.

She never regained consciousness.

“When we realized she was going to die we knew something had gone horribly wrong,” McIntyre said.

Sidney was pronounced brain-dead two days later. The life of the witty, artistic, and kind-hearted teen ended on Jan. 29, when her organs were harvested for donation.

“The loss of our sweet child is utterly overwhelming and the depth of our grief is indescribable,” said McIntyre.

“My daughter’s death was entirely preventable.”

Parents fought for 911 and campus security calls

Sidney’s parents pushed for answers. They filed freedom-of-information requests and obtained recordings of phone calls to 911 and campus security; collected reports from first responders who were on the scene; and spoke with multiple university officials and the students who witnessed Sidney’s collapse.

While students did the right thing by calling for help right away, the parents allege — and the documents strongly suggest — major mistakes were made in the medical response to their daughter’s overdose:

• Sidney and a friend who had also collapsed in the same dorm room were unconscious, struggling to breathe, and turning blue — a sign that the body is deprived of oxygen — when campus security officers arrived 3.5 minutes after being called. The officers carry naloxone and are trained in first aid, but they did not administer the medication for nearly nine and a half minutes and did not start chest compressions for almost 12 minutes.

• Campus security never contacted 911 to explain the seriousness of the situation. Instead, a student who was high on drugs was the only person speaking with 911 for the first 8.5 minutes of the call, despite the fact she had difficulty relaying information about what was happening.

• The 911 call-taker waited seven minutes before dispatching an ambulance to help the two students, even though she was told 3.5 minutes into the call that they were unconscious after seizing.

• The call-taker, who eventually spoke directly with the security officers, did not ask about drugs until 11 minutes into the call and did not advise the officers to administer naloxone for 13 minutes. Fifteen minutes passed before she told them to do chest compressions, despite the second victim making loud gasps for air that were clearly audible during the 911 call.

“Our investigation has revealed systematic failures in the systems implemented by UVic and the province of B.C. A student’s death was inevitable. It was only a matter of time,” Starko said.

Campbell was hesitant to comment specifically on Sidney’s case, but said in this type of situation help needs to be delivered quickly.

“Potentially, if they had been more aggressive upfront in the communication and the instructions in the administration of (naloxone), both these students could have survived,” Campbell said.

Within days of Sidney’s overdose, UVic sent two notices to students and posted one on its website, warning them of the unsafe drug supply in B.C. and informing them where to find naloxone on campus. The emails, though, did not tell students that two people had just overdosed in a dorm, a decision the university said it made for privacy reasons.

The emails continued to encourage students on campus to phone security officers, described as “highly trained medical responders” who carry naloxone, if they need help. “If you or someone around you begins showing any signs of overdose or over-intoxication on campus, please call Campus Security right away. If you’re off-campus, call 911,” the Jan. 26 email says.

‘Very frightened for other students’

Sidney’s death and how her case was handled has national implications. There are more than two million post-secondary students in Canada, and many universities and colleges say on their websites that students on campus should call security during emergencies.

And on many campuses, access to naloxone is not yet widespread or easy.

“That leaves us very frightened for other students who may have a medical emergency on campus,” Starko said.

In response to questions from Postmedia, UVic president Kevin Hall said Sidney’s death was tragic and that “ensuring the safety of our community remains our top priority.”

Several policy changes have been made following her death, such as requiring campus security to now contact 911 directly and improvements to officer training.

But the university defended the actions of its security officers and insisted Postmedia’s timeline of events was wrong, despite the fact the newspaper’s information was based on a transcript and audio recording of the 911 call.

“Although that day ended tragically, (the security officers’) efforts are commendable, and I am proud to work with such a caring team,” said Jessica Maclean, director of campus security.

A statement from the university added: “No time was wasted, and the first aid response was as quick as possible.”

UVic insisted “naloxone was administered within seven minutes” of student witnesses calling for help, even though the 911 recording clearly shows it was 13 minutes. UVic said chest compressions were started three minutes after the naloxone, or about 10 minutes after students called for help, when the 911 call shows it was more than 15 minutes.

The university said it based its timeline on campus security tapes and information from the Saanich fire department, which arrived on school grounds at 6:43 p.m.

Campus security started chest compressions just as firefighters walked into the room, so UVic calculated the time of CPR starting at 6:43 p.m., roughly 10 minutes after the students called for help. UVic then deducted three minutes to determine that naloxone would have been administered about seven minutes after the phone call.

UVic’s chronology, though, didn’t account for the delay between fire trucks pulling into campus at 6:43 and arriving in the dorm room: A student who waited for the firefighters in the parking lot told Postmedia it took them several minutes to remove their gear from the truck and then they had to walk up three flights of stairs to reach the dorm room.

The 911 call indicates firefighters arrived in the room at 6:48 p.m. and that time was confirmed by an ambulance service spokesman.

When Postmedia pointed out that UVic’s medical response times were off by five minutes, the university did not respond.

Sidney’s death was ‘inconceivable’

Sidney’s parents are angered by the lack of accountability from the university. They agreed to share their story with Postmedia to push for improvements at UVic and other post-secondary institutions, including enhanced training of medical responders on campuses and better communication with students about overdoses on school grounds.

“It is inconceivable that eight years into the opioid public health emergency, a student can die from an overdose on a campus when witnesses called for help immediately,” McIntyre said.

The family is also upset about how the 911 call was handled, alleging delays that contributed to their daughter’s death. They’ve filed a complaint with the provincial Patient Care Quality Office.

B.C. Ambulance insisted the call-taker followed protocols correctly. When pressed on whether the call was handled properly, an official noted the call is under review as a result of the family’s complaint.

“We can’t answer that right now because we need to do that review and ensure that it was,” said Bowen Osoko, B.C. Emergency Health Services spokesperson.

Since 2016, more than 14,000 people have had fatal overdoses in B.C.; in recent months, an average of six to seven people have died every day. Overdose is now the leading cause of death for people between the ages of 10 and 59 — more than accidents, suicides, homicides and natural diseases combined.

Despite those alarming statistics, most people who overdose survive: Over the last eight years, paramedics have responded to more than 230,000 overdose calls and kept most patients alive.

Because young people are developmentally at higher risk of making poor choices, McIntyre believes the B.C. government should take steps to better ensure the safety of the 300,000 post-secondary students in the province. Those include making easy-to-use nasal naloxone readily available on post-secondary campuses, giving students simple instructions on how to use it during first-year orientation, and reviewing the emergency medical response rules on university and college campuses.

The Post-Secondary Education Ministry did not answer Postmedia’s questions about those proposals, and Minister Lisa Beare declined to be interviewed. Instead, the ministry issued a short statement that said, in part: “The Ministry will work with all post-secondary institutions to review, build, and strengthen policies and processes where necessary to help reduce the risk of harm on campuses.”

All parents should care about expanding harm reduction supplies and training on campuses, McIntyre said, even if they don’t think their children will experiment with illicit drugs.

Two of Sidney’s closest friends at UVic, Reneé and Lucie (who asked that their last names not be used), say the tragedy left them traumatized.

“I had this dream about her being killed by someone, and I couldn’t save her because she was inside a car. I wanted to save her, I was trying to get into the car, but I couldn’t do it,” Reneé said, adding the grief also affected her and Lucie academically.

“I had a hard time focusing. I failed a couple of midterms. I was not studying for a little bit. And then we started going to counselling, so that helped.

“Sidney was a great friend. We loved her so much.”

For Sidney’s parents, the loss is all-consuming.

They’ve spent more than three months piecing together the final minutes of her life.

“We survive by channelling our anger into documenting what happened to Sidney, and trying to figure out how we can prevent this from happening to another young person,” McIntyre said.

Chronology: How Sidney’s life ended

The following chronology is based on recordings of students’ calls to 911 and campus security, documents from various first responders, and interviews with student witnesses (whose real names have been changed because they remain at UVic).

At 6:15 that Tuesday night in January, roughly one hour after Sidney had FaceTimed with her mother, the young student dropped by her friend Leah’s dorm room on the third floor of a UVic residence building.

Leah told her roommate, Ethan, that she was going to watch a movie in the student lounge with Sidney, who was clad in PJs and a cozy hoodie from her father’s aviation simulation company.

A short time later, several students heard odd noises and a bang in the residence hallway. They found Leah lying in the doorway of a dorm room and Sidney inside on the floor.

Both were unconscious.

“Leah was gasping for air and really jerking,” recalled Emma, a student who rushed to help.

“Sidney, when we got there, was pretty stiff (and) her hand was out and twitching for a bit. And then it stopped.”

Students turned Sidney and Leah on their sides to aid their breathing. Ethan came out of his room, horrified to see the “pale blue bodies” of his friends.

“Everyone was in complete shock trying to figure out what happened, or whether they took something,” he said.

Emma said she would phone campus security, which she was told during first-year orientation to do in an emergency. She yelled for someone else to call 911.

Gwen, who lived in the room where the teens had collapsed, volunteered to dial 911. Unfortunately, none of the other students realized she had consumed drugs and was high.

6:32-6:34 p.m.

The 911 call-taker did not immediately ask Gwen to describe the emergency. For the first three-and-a-half minutes, the operator focused on determining what residence the students were in and where it was located.

Emma, who was sober, called campus security and said two students were “seizing.” She didn’t mention drugs because she, along with the other students who rushed to Gwen’s room to help, had not been with Sidney and Leah immediately before they collapsed, so had no information about what happened to them.

The campus security dispatcher radioed officers to respond and told Emma he would patch her through to 911, but chose not to do so after being told another student had already made the call. The dispatcher kept Emma on the line, telling her to let him know if the victims’ conditions changed.

6:35 p.m.

“They are both turning blue,” Emma said about 30 seconds later. The dispatcher didn’t respond.

After another minute, Emma reported that the victims’ eyes were rolling back in their heads. Still no response.

Emma and the other students in the room said they urged Gwen to tell 911 that the situation was becoming more dire: the teens were both blue from a lack of oxygen, Sidney was motionless and Leah was struggling to breathe.

Gwen, though, had trouble communicating with the operator, who was still focused on determining the building’s location.

6:36 p.m.

The 911 call-taker asked Gwen for the first time why she was calling.

“I’m not 100 per cent sure. I just — they walked in and then they started — just like — they passed out on the floor, and I think they started seizing,” Gwen responded.

“Are they awake?” the 911 operator asked.


“Are they breathing?” 911 asked.

Gwen said she wasn’t sure, but others in the room said they were.

At the same time, on a different phone, Emma told the campus security dispatcher that the two officers had just arrived. The dispatcher, who had been silent for nearly two minutes, then responded: “OK sounds good. If you need anything else, just give us a call back.”

Their first assessment of the students, the security officers noted in their incident report, was that they were “unconscious and both were in respiratory distress.”

The officers asked if the victims had taken drugs, but the students in the room said they didn’t know.

The officers did not pull out the naloxone they were carrying, nor did they start CPR to help the victims breathe.

This was roughly four minutes after the students collapsed, and Sidney’s family believes she would have survived if the officers had made a different decision at this point.

Experts say CPR can greatly increase survival, and there is no risk in giving naloxone even if it’s not clear that someone is overdosing — but time is of the essence. “Somewhere within the four- to five-minute range, people can suffer irreversible brain damage from a lack of oxygen,” said Vancouver emergency physician Dr. Erik Vu, speaking in general and not about this particular case.

6:37-6:39 p.m.

Rather than sending an ambulance, the 911 call-taker asked Gwen a series of questions: Was anyone with them before they passed out? Are they pregnant, diabetic or epileptic? Do they have a history of stroke or brain tumours?

There was no question about drugs.

For the following two minutes, the 911 call-taker tried to establish with Gwen whether the victims were breathing.

Then Leah made a desperate gasp for air.

“What’s that sound?” the operator asked.

“It’s one of the girls,” Gwen said. “I think she’s gulping at the mouth.”

“Is she seizing again,” 911 asked.

“Yes she is.”

Shortly after this exchange, the 911 operator dispatched paramedics. It was seven minutes into the call.

6:40-6:42 p.m.

When Gwen was too confused to explain where the ambulance crews should meet campus security, the 911 operator asked to speak with the officers. It was 8.5 minutes into the call.

Campus security, though, didn’t immediately convey the seriousness of the situation to 911. Despite the alarming background sound of Leah’s intermittent wheezes for air, the operator spent a minute repeatedly asking the guards to count how many times the unconscious students were breathing.

One officer struggled to do this with Sidney, describing her breathing as faint and shallow. After being unable to detect a breath for 40 seconds, he asked his co-worker for his opinion.

The second officer told 911 that Sidney was taking a breath every four seconds, although he later described her respirations as weak and irregular in his incident report. But that description was not provided to the operator, who concluded that Sidney was “breathing effectively.”

Chloe, another student in the room, remembered being frustrated that no one had explained to 911 that Sidney had been blue for several minutes.

“She was just limp and very clearly blue. Like, I don’t think I’ve seen somebody that colour before. It was very obvious,” she recalled.

6:43-6:44 p.m.

For the first time — 11 minutes into the call — the 911 call-taker asked whether the girls had taken drugs and if the officers had Narcan, the brand name for naloxone.

“I think so,” one officer said.

“Yeah, we have Narcan,” the second responded.

Instead of giving the life-saving medication right away, though, the security officers questioned Gwen about drug use. And the 911 call-taker told officers to leave the phone “with the patients” and track down their friends to ask what had happened.

Campbell, the emergency physician, said in the midst of a toxic drug crisis, there should be no hesitation to administer naloxone. “Narcan should almost be part of our primary response, especially in that population of young, healthy students,” he said.

6:45-6:47 p.m.

Gwen admitted for the first time that they’d taken drugs. The security officers passed that information along to the 911 operator, who then instructed them to administer naloxone.

That was more than nine minutes after they arrived on scene, and 13 minutes after students called for help.

Leah regained consciousness after a few minutes, perhaps because her repeated gasps for breath provided just enough oxygen to keep her brain functioning.

Sidney did not respond to the naloxone. “I don’t think I am getting a pulse on this one,” one security officer said.

The 911 operator instructed him to start chest compressions. That was 12 minutes after they arrived in the room.

6:48 p.m.

Just as campus security started chest compressions, firefighters rushed in. They determined Sidney was in cardiac arrest, administered oxygen and took over the CPR.

Paramedics gave Sidney a shot of adrenalin and did CPR for six more minutes, which restarted her heart. She was taken to hospital in critical condition.

Sidney’s last days

But Sidney would never wake up. Her brain had been starved of oxygen for too long.

While she was kept alive in hospital before her organs were donated on Jan. 29, her parents and brother stayed by her bedside and her devastated friends came to visit.

Molly Kingsley, Sidney’s childhood best friend who shared her love for Harry Potter and later the fictional mythology hero Percy Jackson, came to the hospital to say goodbye. She leaned in and whispered in Sidney’s ear.

“I described the plot of the newest episode of the Percy Jackson series that had just come out. And I tried to remind her of various things that we did when we were little, or goofy memories that I have of the two of us,” she said, crying softly.

“I’m glad that I got to see her one more time, but obviously I wish it wasn’t the last time.”

Molly is angry that UVic didn’t alert other students on campus about her friend’s overdose.

Her mother, Mallory Flynn, who works in opioid overdose statistical modelling, added it’s important to share stories like Sidney’s so society understands that every young person, no matter their background, is at risk during this crisis.

“If you could pick a kid that you think this would never happen to, it would be Sidney. She’s the most unlikely. It’s just unbelievable,” Flynn said.

“When in reality, of course, this is happening to so many kids like Sidney.”

After Sidney died, her mother packed up her dorm room. She found a bottle of cider, but no drugs or drug paraphernalia.

“My daughter is no longer here to tell me how she was exposed to fentanyl,” McIntyre said.

“But we believe catastrophic failures by both the University of Victoria and the 911 operator contributed to Sidney’s preventable death.”

UVic has made changes

UVic has not admitted to making any mistakes, but promised the following changes, according to its statement:

• Contacting 911: “We have changed our standard operating procedures since Sidney’s death after this question was raised by her parents. They (campus security dispatch) have now been directed to put medical calls through to 911 and to ensure a connection is made.”

• Security dispatch: UVic maintains the campus security dispatcher monitored the situation and worked with the student who called until the officers arrived in the dorm room, even though he did not speak with the caller for nearly two minutes. It promises, though, to review its current system of rotating security officers through dispatching shifts, and whether it would be better to have dedicated dispatchers.

• Communicating with 911: Despite the impaired student being the only person on the line with 911 for the first 8.5 minutes, UVic said security officers believed “messages were being communicated back and forth.” It added, though, that “this is an area where we have already updated our procedures to improve our process going forward,” but didn’t elaborate on these changes.

• Training: Teaching medical responses to security officers will now be done in-house, rather than continuing to rely on an external contractor. UVic will also hire a training coordinator to provide oversight.

• Naloxone: The university does not plan to expand the areas where students can access the overdose-reversing medication on campus.

911 says operator followed protocols

B.C. Ambulance spokesperson Osoko defended the responses of the 911 call-taker, and provided the following explanations:

• She had to take the time necessary to determine the location of the emergency, even if it took 3.5 minutes. “Sometimes it takes longer than one would hope to find out where paramedics need to be, but it’s the first step.”

• She dispatched first responders seven minutes into the call “as soon as” she learned the students were having seizures and were unconscious, Osoko insisted. (Postmedia pointed out that Gwen provided this information earlier in the call — as soon as the building’s location had been established.)

• Because Gwen described the students as having seizures, the call-taker followed protocols to address that medical emergency, rather than possible overdoses.

• When asked why 911 wouldn’t consider an overdose earlier than 11 minutes into the call — when two students have collapsed in a dorm in the midst of a toxic drug crisis — Osoko said B.C. Ambulance follows its protocols to handle the 1,600 diverse medical-emergency calls it receives a day, and that fewer than eight per cent are about overdoses.

Because Sidney’s parents have filed a complaint over the 911 call, Osoko said he was limited in the details he could discuss and whether any policies will change.

“We’re going to look at everything that occurs in this call, of course, to try to see what can be learned and be able to derive the best, most caring and comprehensive responses to the family that we can,” he said.

Experts not involved in this story say that, in general, there should be no hesitation to use naloxone on an unconscious person in respiratory distress: If they are overdosing, it could save their life; if they are not overdosing, the medication will not harm them.

“Narcan has no addictive properties. And in the sense of someone who is unresponsive and not breathing normally, there is no reason not to give it. Only potential benefit,” said ER physician Vu, who also has specialty training in prehospital care.

In addition, studies show there is a “big impact” on survival if bystanders perform CPR on someone who isn’t breathing normally until first responders arrive. “Just by providing basic life support — so chest compressions and/or artificial respiration — you can keep someone alive from an opiate overdose,” said Vu.

Sidney’s family has penned an open letter to Premier David Eby and other government officials to press for changes they believe the province must make to keep young people safe, and they’ve requested a coroners inquest so lessons can be learned from this tragedy.

McIntyre and Starko have also created a website to document what happened to Sidney and outline several key demands, which include improvements to overdose prevention on campuses, free easy-to-use nasal naloxone in B.C., and mandatory CPR training in the high school curriculum.

“How can B.C. possibly be so far behind other provinces in protecting young people when we have the highest death rate from toxic drugs in the country?” McIntyre asked.

“We are determined to fight for change so a death like this never happens again.”

Editor’s note: Sidney McIntyre-Starko is the first cousin, once removed, of reporter Lori Culbert’s husband.