Errors in UVic's response led to fatal overdose of student, independent report details
Students, family 'not properly cared for' in wake of overdose on campus, report finds
An independent report detailing the "choices and mistakes" that led to the overdose death of a first-year University of Victoria student in January 2024 has been released by the university, casting new light on the circumstances of the incident and her parent's fight for transparency in the year since.
The report, written by former Abbotsford police chief Bob Rich, found that there were "several points" on the night when Sidney McIntyre-Starko overdosed that, had the response been different, she would have likely survived. Another student who overdosed alongside McIntyre-Starko in the residence building was revived by naloxone.
"Sidney, her family, the other students who overdosed, and the students who tried to help, were not properly cared for that night," says the report.
"The only way forward is to look hard at what happened and learn by putting in place more training, rigorous processes, and safeguards so this tragedy is not repeated."
McIntyre-Starko suffered a cardiac arrest due to fentanyl poisoning and died in hospital days after the overdose, according to her parents.
Rich writes that the report follows a commitment made by UVic president Kevin Hall last June, after media reports into McIntyre-Starko's death sparked public outcry over how university officials and campus security responded. It includes 18 recommendations focused on preventing and improving response mechanisms for future overdoses on campus.
Hall said that the university plans to implement all 18 recommendations. Currently, the university is developing an action plan in consultation with a panel of experts that it said it intends to complete by June, and Hall said he hopes to have most recommendations implemented before September.
According to the report, McIntyre-Starko's parents believe that their daughter would have lived if campus security officers had provided her with respiratory support, the report says.
In an email to the CBC, Kenton Starko, McIntyre-Starko's father, said that he hopes the university follows the recommendations — particularly improved first aid training and a medical amnesty policy. He also expressed a desire for mandatory CPR training in high schools.
"We appreciate how thorough and thoughtful Bob Rich was in his report," Starko wrote. "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 added he looks forward to inconsistencies in accounts by witnesses and security officers being explored at the upcoming coroner's inquest into his daughter's death on April 28.
The officers who responded to the scene, who, according to the report, had never responded to a suspected overdose, failed to notice what students present at the scene later reported — that McIntyre-Starko was exhibiting the three key symptoms of an overdose: reduced consciousness, depressed breathing, and pinpoint pupils.
It was only nine minutes after campus security arrived, when officers were told McIntyre-Starko and another student were likely suffering from a drug overdose, that they administered naloxone, Rich's review details. It goes on to say that McIntyre-Starko's parents believe if security had realized this more quickly and provided naloxone sooner, she would not have died.
Officers did not have equipment to provide oxygen in response to a suspected overdose — something the report says UVic has since changed.
The report also outlines numerous hurdles the family faced in accessing information about the circumstances of McIntyre-Starko's death.
On the night of the overdose, the 18-year-old's parents were not alerted by university officials that McIntyre-Starko had been taken to a nearby hospital. A student who witnessed first responders attending to McIntyre-Starko alerted her brother, who was also a student at UVic at that time, the report says.
It took "several hours" for McIntyre-Starko's brother to find her after reaching the hospital. When he did, she had been placed on a ventilator and hospital staff told him she was in "very serious condition."
The brother alerted his parents. However, by this time, it was too late for McIntyre-Starko's mother, who was in Vancouver and would have to travel to Victoria by ferry the next morning. The teen's father, meanwhile, was out of the country.
McIntyre-Starko's family sought answers in the months that followed her death, including an accurate timeline of the events surrounding the overdose. After "lengthy" exchanges with campus officials, the family was told to submit a freedom of information (FOI) request for the information they were looking for. The family met with UVic president Kevin Hall — a meeting that "ended poorly," according to the report.
Ultimately, the family spoke to a reporter from the Vancouver Sun for a story that sparked a flurry of media attention, public outcry, and the creation of a provincial committee to examine post-secondary overdose prevention and response.
Students, family 'not properly cared for' in wake of overdoses, report finds
The report provides a detailed timeline of the night McIntyre-Starko died, based on interviews with more than 50 people, including students, UVic staff, first responders, and the teen's family.
It was the first time McIntyre-Starko had tried unregulated street drugs, according to the report. She and two other first-year students living in residence in January 2024 had planned to take the drugs — which students later said were found by a friend— and watch a movie together.
Shortly after ingesting the drugs, a powder that contained a mix of cocaine and fentanyl, McIntyre-Starko and another student lost consciousness. The report says students called campus security and first responders to the scene. It explains, initially, that the third student who had taken the drugs denied that they had taken anything — which led campus security officers to believe McIntyre-Starko and the other student were experiencing seizures. However, the student later said there was a "high probability" they had consumed drugs.
After McIntyre-Starko was taken to the hospital, Rich's report says first responders left students to watch over the two others who had taken drugs. They were throwing up and feeling "very unwell," prompting another call to 911, at which point the pair was taken to hospital where they were checked by medical staff.
University officials did not meet to discuss how to respond until the next morning. Officials proposed it was too late – or potentially the hospital's duty – to alert the parents and faxed a letter days later for the hospital to deliver to them.
Although UVic staff had been aware of numerous recent overdoses in and around campus, the emails that went out to students after McIntyre-Starko's death did not say that the unregulated drug supply near UVic was currently toxic and unsafe, which the report says "was the primary purpose of those emails." The emails also did not say that a student had died, the report continues.
Changes proposed
The report's 18 recommendations for UVic include designating university officials to oversee and investigate critical incidents on campus, the creation of crisis communications and family liaison roles, additional first-aid training and resources, and implementing and advertising a medical amnesty policy for those calling for help with a suspected overdose.
Hall said he was grateful for the report and its recommendations.
"What happened to Sidney was a tragedy," he said. "We're really looking forward to implementing the recommendations … UVic's responsibility is to continue to improve our systems and our policies and processes so that we create that safe campus."
When asked, Hall would not say whether he agreed with the report's assessment that mistakes made by UVic led to McIntyre-Starko's death, but said he anticipates the coroner's inquest will look into this in more detail.
Prior to the report, UVic had made some changes since the incident in January 2024 – including opioid emergency kits with nasal naloxone on every student residence floor, training to use the kits for all student residence staff, hiring a trauma counsellor for residence staff, and hiring an officer experienced in first aid to train campus security staff.
Two weeks before releasing the report, UVic held a meeting with 50 students to hear their feedback on harm reduction and harm reduction supplies on campus as part of a research group looking at harm reduction on campus.
However, Rich noted that the issue is not solved "nor is it static."
"Sidney's life was full of hope, promise, potential and love," the report says. "Nothing in this review can take away the pain of that loss."
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