911 operator relied on what witness described as seizures of uvic students, coroner's inquest hears
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the 911 call-taker involved in the drug-poisoning death of a university of victoria student testified at a coroner’s inquest that she suspected two collapsed patients in a campus residence could be overdosing.
but kylie alfano said witnesses described the two students as “seizing,” so she followed the seizure protocol on her 911 computer system screen.
“my suspicion from the beginning was that (overdose) was a possibility,” alfano testified.
“(but) we are taught to trust the caller at all times, and we need to stick to the script at all times. we cannot deviate or ask leading questions.”
one of the central issues being examined at sidney mcintyre-starko’s inquest is why her overdose was mistaken for a seizure, and why she didn’t receive the overdose-reversing drug naloxone for 13 minutes, or cpr for 15 minutes. the 18-year-old died of oxygen deprivation.
the student who called 911 on jan. 23, 2024 said sidney and a second student were “seizing” and turning blue, but did not disclose that they had taken drugs.
that took alfano into a seizure protocol in the 911 computer system that call-takers, who are not paramedics, use to evaluate emergencies based on the information provided by witnesses.
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her computer screen flashed a warning sign that it was unusual for two patients to have a seizure at the same time.
despite toxic drugs being the leading cause of death for people ages 10 to 59, alfano testified she has been trained to rely on the information provided to her by the caller who is her “eyes and ears” at the scene.
“we’re not allowed to make assumptions… we have to go by what the caller tells us,” she testified.
“(if) we make assumptions, and we’re wrong, it can harm patients. so we need to stick to those scripts because they’re put in place by medical professionals.”
unfortunately, in this call, it was alfano’s assumption about overdoses that was correct, and not the seizure protocol on her computer screen.
sidney mcintyre-starko in victoria during her first year of university. photo courtesy sidney’s family
if the call had been logged as a cardiac arrest, that would have triggered a high priority for an ambulance to be dispatched compared to seizure calls, alfano said.
the student who called 911 reported the patients as turning blue, typically an indication that they are struggling to breathe. but alfano said she typed that they were breathing into her computer system based on witnesses at the scene saying they thought they were breathing.
twelve minutes into the call, alfano asked the security guards on scene if they had naloxone, and was permitted to recommend its use for a “suspected overdose.” but the suspicion has to come from someone on scene, not from the call-taker, to proceed with the overdose-reversing medication, she testified.
she said she knew it is safe to give naloxone to someone, even if they are not overdosing.
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another reason why medical assistance was delayed for sidney is because it took alfano three and a half minutes to find a location for the uvic residence, which has been on the campus for more than 50 years. part of the confusion is that every building on campus shared a universal address, an issue that has been fixed since sidney’s death.
on friday, alfano testified the time it takes to find an address is critical before first responders can be sent.
“the most important thing we learn as call takers is that we need to find where the patient is first before we can send help there,” she said.
under cross examination by justin giovannetti, a lawyer for sidney’s family, alfano agreed that one and a half minutes into the call she had the general address for uvic, the name of the residence and the room number — the information that first responders ultimately used to find the emergency.
in the next two minutes, she tried to determine an exact address for the residence but couldn’t find it and ultimately moved on to ask the caller to describe the emergency for the first time, three and a half minutes into the call.
time was of the essence in this call because, medical experts say, the majority of overdoses are survivable if cpr and/or naloxone are delivered within minutes of a collapse.
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in most overdose calls, alfano testified, the caller provides information about drug use. she said it is “disheartening” when that isn’t offered immediately.
“it’s really hard because as a call taker, we want to help. we’re not there to judge anybody, and we want the most information in order to help the patient,” she said.
the inquest continues monday.
the presiding coroner, larry marzinzik, explained that the inquest will determine facts related to the death, to make recommendations that may prevent similar deaths in the future, and to satisfy the community that the death is not being ignored. it does not determine blame for the death.
sidney’s death has led to better access to naloxone and other harm reduction measures on campuses, and attempts to improve first aid policies. sidney’s parents have lobbied for these improvements through their sidneyshoudbehere campaign, and hope the inquest will lead to changes in b.c.’s 911 system, to avoid a similar preventable death from happening in future.
twelve lawyers are representing various agencies at the inquest, including uvic, the ambulance service and the ministries of health and post-secondary education.
the inquest is scheduled for three weeks, with 33 witnesses scheduled to testify.
you can follow ongoing coverage of the inquest here:
• day 1: uvic student’s mother takes stand on day 1 of her coroner’s inquest
• day 2: uvic student contradicts campus security evidence at coroner’s inquest
• day 3: uvic security officer defends actions on day of student overdose death
• day 4: we ‘did the best we could’: second uvic security guard testifies about evening student died
• day 6: paramedic suspected fatal uvic call was more serious than 911 report
• day 8: u.s. doctor tells inquest b.c. 911 operators don’t use best approach to cardiac-arrest calls
• day 9: after death of uvic student, changes aim to trim delays in getting paramedics to patients
• day 10: b.c.’s 911 system needs major changes, emergency care expert says
• day 11: u.s. firm that made b.c. ambulance’s 911 dispatch system told how to fix it
• day 12: b.c. coroner’s jury deliberating changes to ambulance, education systems
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