inquest jury recommends changes to b.c. ambulance, education systems
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a coroner’s inquest jury has recommended major educational changes concerning the toxic drug crisis and how ambulances will respond to emergencies, in response to the preventable overdose death of a university of victoria student.
after hearing 11 days of testimony about the fentanyl-poisoning death of sidney mcintyre-starko, 18, the five-person jury made 10 recommendations that include providing cpr training and toxic drug awareness to high school students; changes to first aid attendants and building locations on post-secondary campuses; and improvements to the 911 system to speed up how call-takers locate emergencies and prioritize all calls with multiple unconscious patients.
sidney’s father, ken starko, said thursday that their family is grateful for the jury’s work to create recommendations to prevent similar deaths, in particular the ones directed at teaching young people basic first aid.
“every child deserves an education in cpr,” he said.
however, starko said the inquest, a truth-finding mission to find out how and why is daughter died, was far too “political.” he noted 10 lawyers represented various government or private agencies, at times objecting to evidence or witnesses being called.
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“our family … would like to thank all the people who loved and supported sidney in her short life, and all the people who continue to hold us up,” he added.
when sidney and another student collapsed in a uvic dorm in january 2024, their friends phoned campus security and 911 for help immediately. but sidney died of oxygen deprivation after not receiving the overdose-reversing drug naloxone for 13 minutes, or cpr for 15 minutes.
on wednesday, before the jury issued their recommendations, premier david eby promised they would be implemented, noting “there are issues that have come up in terms of the ehs (emergency health services) response during the coroner’s inquest.”
he added this case was important “in relation to how post-secondary schools deal with this issue of students who may think they’re just having a good time with friends and then suddenly end up an overdose situation, and how we can minimize harm in that very specific environment.”
the jury forewoman became emotional several times thursday while reading out the 10 sweeping recommendations. they include:
ministry of education: secondary schools should provide instruction on how to perform cpr, administer nasal naloxone, and use automated external defibrillators (aed); create a presentation for students that highlights the effects and risks of taking drugs; and make that available on a website for parents and others to access.
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the jury forewoman said this was based on school boards in other provinces doing this training, and that it’s important to reach young people because toxic drugs are now the leading cause of death for british columbians aged 10 to 59.
post-secondary ministry, b.c. emergency health services: consult with post-secondary schools and municipalities to ensure there are unique addresses for each building in multi-building complexes. and that the addresses are clearly posted on the buildings, are included in maps used by first responders, and those maps are updated annually. install a building map on the back of each campus residence door and in common areas that includes the nearest “muster point” where campus security will meet first-responders.
post-secondary ministry: campus security at all universities and colleges should have devices to supply oxygen, finger monitors that can detect a pulse, naloxone, aeds, and at least the second level of occupational first aid training. the jury forewoman noted there were “multiple debates” at the scene about whether sidney was breathing.
having those devices would provide a more reliable answer than the “breathing diagnostic tool” the 911 call-taker was directing the officers to do based on directions from her computer system.
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the jury recommended that families of students are notified within one hour of a serious medical emergency, noting sidney’s parents did not hear from anyone at uvic that evening which robbed them of valuable time with their daughter before she died.
and that campus counsellors should check on the well-being of students after one of their friends dies. “contacting the students in person will show more compassion and instigate more healthy processing of the event,” the forewoman said.
b.c. emergency health services: review policies on obtaining patient identification, because the paramedic did not have sidney’s name when she was admitted to hospital. by the end of 2025, update the computer-aided dispatch (cad) system used by dispatchers, which is about 17 years old and outdated. upgrade its website so it can live up to its promise to make data — such as call response times — publicly available.
the ambulance service is also to incorporate an internal timer to monitor how long call-takers spend trying to find an address, which will alert their supervisors if too much time passes.
the jury heard it took the call-taker seven minutes to dispatch an ambulance, partly because she spent 3½ minutes trying to find a specific location for the uvic dorm, which didn’t have its own address and didn’t show up in the provincial mapping system used by 911.
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priority dispatch, the creators of the computer system used by ambulance call-takers: update the system so that when a call involves multiple unconscious patients, a high-priority ambulance should be dispatched immediately and the call-taker should ask followup questions about possible drug use.
the jury has heard that sidney’s emergency response was delayed because the student who called 911 didn’t explain she and her friends had taken drugs, and described the two patients as turning blue and “seizing.” that caused the call-taker to enter the seizure protocol on her 911 computer system, which provided a less urgent response to the two unconscious patients.
post-secondary ministry: provide campus security staff with scheduled work time to review training every semester, require officers to complete a report after a serious incident and undergo a debriefing with managers. install security cameras in high-traffic, public areas such as the bus loop to help verify details of serious incidents.
if students are administered naloxone but decline to go to the hospital, which happened with two of the students in this case, campus security should check on them every 30 minutes for the next 1½ hours — the length of time it takes for naloxone to wear off.
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university of victoria: create a mandatory online orientation to be completed by the end of the student’s first year, to include: how to contact 911 and campus security, how to access naloxone and administer it, how to use aeds, how to find drug-testing locations and that using them comes with no repercussions, and general information on the drug crisis.
and include this online information in campus security training. this was suggested because one security officer testified he didn’t believe medical evidence that naloxone is benign and will not cause harm to a patient even if they are not overdosing.
post-secondary ministry, ministry of education: create in-person presentations on the drug crisis for secondary and post-secondary students, using real stories from survivors and family members to make the most impact on young people.
sidney’s family, which has pushed for changes, hopes more progress will be made in light of their daughter’s preventable death.
“in b.c., someone who is unconscious and blue deserves an ambulance sent immediately whether they are ‘seizing’ or not,” starko said.
with files from alec lazenby, postmedia
you can recap coverage of the inquest here:
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