The overdose death of an 18-year-old student in residence at the University of Victoria was likely preventable, and university officials fumbled the response during the medical emergency and in the days and months afterward, a new report has found.
Sidney McIntyre-Starko died after ingesting a mixture of cocaine and fentanyl with two other young women in a campus residence bathroom on Jan. 23, 2024. The three friends did not know what was in the vial of white-grey powder they had obtained but divided the contents into three lines and snorted it, knocking two of them unconscious.
The 123-page report by former Abbotsford police chief and lawyer Bob Rich was commissioned by the university. Mr. Rich, who made 18 recommendations to change campus culture around drug risks, established a detailed timeline of the events around Ms. McIntyre-Starko’s death.
He found multiple missteps by the university and first responders: A lack of training meant first responders failed to recognize the signs of a drug overdose. The young woman’s family was not notified that she was in hospital on life support. And fellow students were left to monitor the health of her two friends who had ingested the same toxic drugs.
“There were choices and mistakes made throughout the evening that ultimately led to Sidney’s death,” he wrote. “Like many tragic events, there were several points where, had the response been different, Sidney likely would not have died.”
Mr. Rich’s report described a chaotic scene in the small dorm room where Ms. McIntyre-Starko, turning blue and in cardiac arrest, lay on the floor. First responders had to push their way through a noisy crowd of onlookers in the hallway outside.
“The response by the university to this medical crisis that night was not well co-ordinated 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,” Mr. Rich wrote.
Sidney’s death prompted B.C. postsecondary institutions to promise new measures aimed at preventing overdoses, which include distributing and implementing training standards for Naloxone, the medication that reverses the effects of opioids.
A coroner’s inquest into Sidney’s death is set to begin later this month.
Kenton Starko, Sidney’s father, thanked Mr. Rich for the “thorough and thoughtful” report, but said he hopes more answers.
“It remains impossible for us to understand how the responding officers were not better prepared,” he wrote in an e-mail response to The Globe and Mail. “The inconsistencies in the accounts by witnesses and security responders will be better explored at the coroner’s inquest of April 28.”
Mr. Starko said the family expects UVic to follow Mr. Rich’s recommendations, particularly around improved first aid training, and a well-advertised medical amnesty policy that would ensure students are not afraid to ask for help when substance use is involved.
The report’s chronology notes that the university had been alerted to a string of suspected drug overdoses on campus but delayed sending out an alert to students until after Ms. McIntyre-Starko’s death.
The three students inhaled the drugs at roughly 6:15 p.m. and 15 minutes later, Ms. McIntyre-Starko collapsed in one of the residence bedrooms. Another student, who is only identified in the report as “affected person 1″ collapsed in the hall just outside. The third friend who had consumed drugs, identified as “affected person 2,″ told witnesses that her friend was sleeping, and told first responders that her friends were having seizures after running around in play. She initially denied they had taken drugs.
That misinformation led first responders to treat the two unconscious women for seizures instead of drug overdoses.
It was nine minutes after campus security arrived as the first responders before Naloxone was provided, which revived one of them. Ms. McIntyre-Starko was taken by ambulance to hospital, while the other two who had shared the same toxic drugs were monitored by other dorm residents. It was a witness in the dorm who reached out to Ms. McIntyre-Starko’s brother, who also attended UVic. Her brother then spent hours at the hospital searching for her, because she arrived with no name or identification.
In a statement, UVic’s president and vice-chancellor Kevin Hall said the institution accepts all of the report’s recommendations. “While the university has taken action over the past year to improve safety on campus, there’s more to do and we’re committed to the work ahead.”