A first-year University of Victoria student poisoned by fentanyl failed to receive the basic medical response that could have saved her life, according to a report by a retired police chief. Read More
New review by retired Abbotsford Police Chief Bob Rich is critical of the university’s response to the overdose of two first-year students. One of them died.
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New review by retired Abbotsford Police Chief Bob Rich is critical of the university’s response to the overdose of two first-year students. One of them died.
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University of Victoria staff failed to provide the basic medical response that could have saved the life of a first-year student who was poisoned by fentanyl on campus, according to a critical new report by a retired police chief.
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“The response by the university to this medical crisis that night was not well co-ordinated or thought out,” says the external review of the January 2024 death of 18-year-old student Sidney McIntyre-Starko.
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“Sidney, her family, the other students who overdosed, and the students who tried to help, were not properly cared for that night.”
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The report was written by Bob Rich, a lawyer and retired Abbotsford police chief. The university commissioned him to review the events surrounding Sidney’s death, after her family and the provincial post-secondary minister raised concerns, which were all documented in a series of Postmedia stories.
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“Like many tragic events, there were several points where, had the response been different, Sidney likely would not have died. Once Sidney 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,” Rich wrote.
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UVic has since done “substantial work” to reduce the risk of overdoses on campus and, when one occurs, to ensure that first responders will get there more quickly and have better training, the report says.
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But more work needs to be done to protect students in the midst of B.C.’s nine-year overdose crisis, said Rich, who spent six months interviewing more than 50 people and listed 18 recommendations for change.
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In a statement, UVic President Kevin Hall accepted the recommendations and said implementing them was important to ensure “Sidney’s death leads to meaningful and lasting change.” He provided no timeline for the changes.
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Reporting by Postmedia revealed that when Sidney collapsed in a UVic residence on Jan. 23, 2024, students didn’t have nearby access to naloxone, campus security officers waited too long to administer it, and the 911 operator also hesitated to recommend using the medication or to start CPR.
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Sidney died of oxygen deprivation.
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Last May, when Postmedia first asked about the case, UVic officials insisted the actions of its security officers were “commendable.” They also denied evidence from the 911 recording that Sidney didn’t receive naloxone for 13 minutes or chest compressions for 15 minutes after her collapse.
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Student witnesses who called first-aid-trained campus security for help described Sidney and a second student who overdosed as “turning blue,” a medical sign that they may have low oxygen levels, the report says.
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One of two UVic security guards who responded told Rich he concluded Sidney was breathing after placing his hand by her mouth and watching her chest rise. However, the carbon dioxide levels in her blood, tested a short time later by paramedics, were consistent with someone who had not been breathing for 17 minutes, the report says.
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“The assessment of the effectiveness of Sidney’s breathing appears to have been problematic,” Rich wrote.
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Sidney was wearing a baggy sweatshirt and lying on her side, which would make it hard to see if her chest was moving. The 911 dispatcher, who was on the line with another student, also failed to tell the security officers “what to look for to determine if she was breathing,” the report says.
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This was the first drug-poisoning call for the two security guards, who did not check the students’ pupils, which typically turn small during an overdose. They also told Rich they didn’t notice whether the students’ skin was blue, possibly because the light in the room was dim.
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Security officers respond to a variety of calls on campus and UVic had done “little analysis” of what training they needed, including the level of first aid, Rich wrote.
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When Sidney was taken to hospital, several university administrators were informed that night, but her family was not told because each official thought someone else was doing it, Rich discovered.
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No one from the university went to the hospital that night to check on Sidney, no one besides the security guards spoke with the student witnesses, and no one was assigned to monitor two other students who had taken the same drugs, who later that evening also went to the hospital.
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About four days later, the university wrote a letter to Sidney’s parents and faxed it to the hospital, Rich said.
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That week, two emails were sent to all UVic students with general information about unsafe street drugs and local resources, but didn’t mention concerns raised by the campus security director of “a noted increase” in overdoses on campus.
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“Neither of these emails warned students that the unregulated drug supply in the UVic area was currently exceptionally toxic and unsafe,” Rich wrote.
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The three students involved in this case knew about fentanyl but likely thought they’d be safe using the drugs together, Rich said. The outcome of that evening might have been different if UVic had clearly warned all students that 80 per cent of illegal drugs are contaminated with fentanyl and can cause overdoses, he added.
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“The evidence is that Jan. 23 was the first time Sidney tried using unregulated drugs. It was an experiment that the three students hoped would be an enjoyable new experience as they set out to enjoy an evening together watching a movie,” Rich wrote.
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Uvic called in their response co-ordination team to address Sidney’s overdose the next day, which Rich said was “too late” because someone needed to take charge of the situation that night.
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The campus security director, who was new to her job, thought an investigation into the case was needed. But when she asked UVic staff how the incident should be analyzed, she was told the coroner — who determines only the victim’s cause of death — would investigate.
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“The response that took place on the evening of Jan. 23, 2024, and in the days and months that followed was not adequate,” says the report.
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Rich’s 18 recommendations include calls for UVic to:
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•Improve its system to assess risks for students and use it more frequently, create a “person in charge” to oversee responses to critical incidents, and ensure there is a trained family liaison to answer questions for victims’ relatives
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• Provide campus security with a more advanced, 40-hour first responder training course that teaches first aid and CPR, create a campus security investigator position, and review if more security officers need to be hired
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• Ensure residence staff can provide basic first aid, including administering naloxone, and that the overdose-reversing drug be brought on field trips
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• Improve the accessibility of harm-reduction supplies on campus, ensure students are well informed of the fentanyl drug crisis, and guarantee students who report overdoses don’t get in trouble with the university, and hang posters in residences to emphasize this
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That type of amnesty policy could have saved Sidney’s life, Rich wrote, because students at the scene may have been less hesitant to tell campus security that drugs had been involved.
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Responding to the recommendations will be up to university administration, which Rich wrote has struggled in the past to adapt to change, including a proper response to the drug crisis.
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“This cannot be a tick box exercise. It will require a change in culture,” he wrote.
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Rich’s report detailed the policies that existed at UVic to handle critical incidents before this case.
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“Unfortunately, what happened on Jan. 23 showed that these risk management processes were not robust and did not meet the moment.”
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Sidney’s parents, Dr. Caroline McIntyre and Ken Starko, said they hope inconsistencies in accounts by witnesses and security officers that were identified in Rich’s “thorough” report will be explored at the coroner’s inquest, which starts April 28.
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“It remains impossible for us to understand how the responding officers were not better prepared, given campus security responded to an unconscious person who required both naloxone and chest compressions just one week prior,” McIntyre, an emergency physician, said Thursday.
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“We hope the university follows the recommendations. In particular, improved first aid training, and a well-advertised medical amnesty policy that would ensure every student is aware that they will not get in trouble for calling for help when substance use is involved.”
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The parents will continue to push for other changes highlighted on their “Sidney Should Be Here” website, including mandatory CPR training in high schools so young people know how to help during an emergency, said Starko.
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Rich said there are “inconsistencies” in how the students got the drugs that night.
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One teen said a cardboard box with alcohol coolers was found on the sidewalk and brought back to the Sir Arthur Currie dorm, where students found a small vial with white or grey powder. Police told Rich it was cocaine laced with fentanyl.
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The report said two students rubbed the powder on their gums but did not have a reaction. The next evening, three students used a straw to inhale some of the powder in the third-floor bathroom.
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One of students, who survived, told Rich she noticed Sidney’s pupils were tiny before they left the bathroom.
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People who do not use street drugs have no tolerance for them, so they react more quickly to their effects. Sidney was not known by family or friends to take illegal drugs. A search of her dorm room showed no drug paraphernalia or any evidence of past drug use.
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The group of inexperienced, young student witnesses told emergency responders that night that Sidney and the other student who collapsed looked like they were “seizing.” That contributed to the 911 call-taker and the security guards thinking the students were having seizures and didn’t need CPR.
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“When the security officers arrived on scene all three primary symptoms of an overdose were present in Sidney,” Rich wrote.
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“The problem is that fentanyl can cause seizure-like symptoms, and hypoxia, the lack of oxygen in the body’s tissues if there is suppressed breathing, can cause a seizure,” Rich added.
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“This illustrates the need to provide more in-depth training on the when, and not just the how, to provide respiratory support or CPR, especially if the patient has seizure like symptoms.”
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After The Sun published Sidney’s story in May 2024, the post-secondary minister called an emergency meeting with the administrators of B.C.’s 25 universities and colleges, and created an overdose-prevention committee to address medical gaps on campuses.
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UVic admitted last June that “mistakes were made” in Sidney’s case and vowed changes on campus, including 89 new nasal naloxone boxes. Other post-secondary schools made similar changes by September.
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In response to Sidney’s case, the province has promised a long list of changes at universities and colleges, secondary schools, and in the health system. The coroner’s inquest is scheduled for three weeks.
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