The University of Victoria released a report on Thursday following the opioid death of first-year student Sidney McIntyre-Starko in January 2024.
The report makes 18 recommendations for the university to make the campus safer, all of which the university accepted.
“Like many tragic events, there were several points where, had the response been different, Sidney likely would not have died,” the summary of the report states.
The report looked at the timeline on the night McIntyre-Starko died, the decisions that were made and the conversations that were had.
On Jan. 23, 2024, the 18-year-old was one of three first-year students living in residence at the university who took drugs, which they knew came from the unregulated drug supply in B.C. The drug was later determined to be cocaine laced with fentanyl.
The report found that there are inconsistencies in the accounts of how the three students came into possession of the drugs. Two of the students who took the drugs with McIntyre-Sturko initially said a fourth friend had found a cardboard container on a sidewalk in downtown Victoria that had alcoholic coolers in it.
That fourth person took the box back to the residence and when she left, the three students found a vial in the container with powder in it and decided to try it the next day.
However, it is not clear where the drugs came from, the report said.
The next day, the three students inhaled the drugs using a straw in the third-floor washroom of the Sir Arthur Currie residence on campus.
McIntyre-Starko and another student, who is not identified, fell unconscious and other students on the floor called campus security.
The third student, who is also not being identified, took the drug and did not fall unconscious and called 911.
According to witnesses who called campus security, they thought the two girls were having seizures. Both were turning blue but that was not relayed to security officers when they turned up, the report states.
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The third person who had taken the drugs but was not unconscious told the security officer that the two girls were running around “playing” when they collapsed.
When the second security officer arrived, he states that he was able to detect shallow breaths coming from McIntyre-Starko but he could not detect a pulse.
It wasn’t until the third person who took the drugs was asked whether the other two took anything that she said, “There is a high probability they took something.”
That is when the security officers administered nasal naloxone to the two students but McIntyre-Starko doesn’t wake up and it was discovered she had suffered a cardiac arrest at some point, although the exact time is unclear.
She was rushed to the hospital and put on life support.
The report found that although key staff members were made aware of what happened that night, no one took charge of directing a coordinated response.
The associate director of campus security (ADCS) and the director of student life (DSL), discussed the need for Residence Services to call McIntyre-Starko’s family but the report found that the ADCS assumed that staff in Student Affairs would work out who would call the family but what became clear is that no one did that night.
“This meant that for most of the evening on Jan. 23, Sidney’s parents, Caroline McIntyre and Kenton Starko, were not aware their daughter was in hospital in critical condition,” the report states.
McIntyre-Starko’s brother is also a student at UVic and he was eventually told his sister was in the hospital. He rushed there but it took him a few hours to find her and when he did he found that she had been placed on a ventilator.
Due to the time, Caroline McIntyre was not able to travel to Victoria until the following morning on a ferry. Kenton Starko was out of town on a business trip.
“From the time that (a witness) called Campus Security to the first security officer arriving on the 3rd floor of Sir Arthur Currie was just under four minutes,” the report states.
“From the time that the first security officer arrived on scene until they administered naloxone was nine minutes. CPR was begun on Sidney approximately 12 minutes after the first security officer arrived.”
The report found that if the security officers and first responders knew they were dealing with a drug overdose, then naloxone would have been administered earlier.
“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.”
The University of Victoria said it is committed to improving safety on campus and preventing something like this from happening again.
“We’ve always had information for students available on our website, it probably wasn’t in the best location, it probably wasn’t as relevant, and I think when we look at the nature of this crisis it’s changing constantly,” university president Kevin Hall said.
“The issue of issues and crises facing students at a university is changing constantly, and we have to be prepared, as Mr. Rich reminded us, to be agile, and to make sure we can continue to adapt and change, to show up the best every time.”
The report was conducted by former Abbotsford police chief and lawyer, Bob Rich, over a period of six months and involved interviews with more than 50 staff, students, first responders and experts.
A coroner’s inquest into McIntyre-Starko’s death is set to begin later this month.
In a statement, McIntyre-Starko’s father said they appreciate how thorough and thoughtful Rich was in his report.
“Although 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,” he said.
“The inconsistencies in the accounts by witnesses and security responders will be better explored at the coroner’s inquest of April 28.
“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 receives the care they need when substance use is involved. Students should be confident that they will be protected against disciplinary action.”
Starko said they also want mandatory CPR training in all high schools.
Their other recommendations can be found on their website.
“The response that took place on the evening of January 23rd,2024, and in the days and months that followed was not adequate,” the report states.
“Responding to a crisis requires a constant evaluation if the right steps are being taken and course correction if they are not.
“It is important to point out that the many changes the university has now put in place are significant.”
