Jury makes 10 recommendations after coroner’s inquest on UVic student’s overdose

After multiple days of deliberation, the jury in the coroner's inquest into the death of a University of Victoria student returned its verdict Thursday.

A coroner’s inquest jury has made 10 recommendations that its members believe would help prevent future deaths like Sidney McIntyre-Starko’s.

The 18-year-old University of Victoria student died of an accidental overdose in a dormitory on the school’s campus in January 2024.

McIntyre-Starko and two other students ingested what they thought was cocaine, but turned out to be tainted with fentanyl. Two of the students overdosed, and McIntyre-Starko did not survive.

• Read more: Jury at inquest into UVic overdose death continues deliberations

The jury’s verdict and recommendations were read out Thursday morning.

The five-member panel ruled the death an accident and addressed recommendations to five different entities: The university; B.C.’s ministers of education and child care and of post-secondary education and future skills; BC Emergency Health Services; and the International Academy of Emergency Dispatch.

The jury’s first recommendation was to the minister of education and child care, who it said should recommend that school districts implement instruction on CPR, demonstration of the usage of AEDs and nasal naloxone, and presentations on drug identification, effects and risks in high schools.

Second, to both ministers, the jury recommended creating “a program involving in-person, informative and compelling presentations about the drug crisis using real stories from survivors and/or family members of loved ones lost.” Such a program should be made “available to all post-secondary institutions and high schools (public and private),” according to the jury.

The province said it has made changes since McIntyre-Starko’s death, including distributing nasal naloxone to all post-secondary institutions and creating a Post-Secondary Overdose Prevention and Response Steering Committee.

“I would like to offer my deep thanks to Sidney’s family for their courageous advocacy, and acknowledge this advocacy is born of grief and love,” said Minister of Education and Child Care Lisa Beare, in a statement.

“They have taken time over the past year to meet with my colleagues and I to share Sidney’s story. We are also grateful to the work of the coroner and the jury in providing these recommendations and all those who participated in this inquest.”

To UVic, the jury recommended creating a mandatory in-person or online orientation for first-year students that goes over how to contact 911 and campus security, how to obtain and safely administer naloxone, and information on AEDs and drug testing services.

It also recommended that the university give the same course to its campus security officers as part of their training.

A key point of emphasis in the recommended course would be ensuring students know they will not face repercussions for accessing naloxone or drug testing, a focus that likely reflects the fact that the student who called 911 did not initially mention that McIntyre-Starko and her friend had ingested drugs, instead describing their symptoms as seizures.

The university said it will take time to thoroughly review the jury’s findings and recommendations.

In a statement, Kevin Hall, the school’s president and vice-chancellor, said he extends his deepest sympathies to McIntyre-Starko’s family on behalf of the entire UVic community.

“Universities and colleges across British Columbia have work to do, collectively, to help safeguard their communities against toxic drugs. The University of Victoria takes its role in this seriously,” Hall said.

“We remain committed to learning from this tragedy and taking the steps necessary to foster a safe and supportive environment for everyone at UVic.”

To the minister of post-secondary education and future skills and BC Emergency Health Services, the jury recommended consulting with post-secondary institutions and the municipalities in which they are located to ensure that each building on a multi-building campus has a unique address that is clearly labeled and included on campus maps and inside residences.

The first three-and-a-half minutes of the 911 call about McIntyre-Starko’s overdose were spent with the call-taker attempting to establish exactly where on campus the incident had occurred.

“Time is critical. Very critical. What happened? Why did this happen? Why were there failures made?” said lawyer Tony Vecchio, whose firm represented McIntyre-Starko’s family pro bono at the inquest.

The province said it has already made some changes to the emergency dispatch system and it expects “additional action stemming from these new recommendations will build on that work.”

The jury also recommended to the minister that all post-secondary schools could have additional equipment provided to their campus security, including supplemental oxygen, oxygen monitors, naloxone and AEDs.

The minister should also direct post-secondary institutions to make several changes, according to the jury. Those changes are enumerated in recommendation seven as follows:

• Provide scheduled work time for security officers to review training manuals, protocols and best practices every semester, with completion of these reviews documented;
• Direct campus security to connect the caller with 911 regardless of any other calls to 911 being made;
• Conduct debriefings after serious incidents;
• Require security officers to complete incident reports for serious incidents by the end of their shifts, with the director of campus security reviewing those reports every 48 hours;
• Install surveillance cameras in public areas such as bus loops;
• Create policies to clarify who is responsible to call the emergency contact person for a student who is unconscious or in a serious medical emergency within one hour;
• Maintain contact with a person who has received naloxone but not been taken to hospital, checking in every 30 minutes over the next hour and a half;
• Ensure that campus counsellors or mental health support workers check in with students who witnessed events leading up to serious incidents such as the death of a student;

To BCEHS, the jury recommended reviewing its policies on obtaining identification and dispatch technology upgrades. It also recommended incorporating an internal timer to monitor how long it takes to obtain the location where an incident occurred.

Finally, to the International Academy of Emergency Dispatch, the jury recommended that the academy “consider updating the MPDS system so that when multiple unconscious patients are reported, the system generates an immediate delta response and a follow-up question regarding the possibility of drugs being involved."

McIntyre-Starko’s mother and father attended every day of testimony at the inquest and when it was over expressed their gratitude to the two men and three women on the jury, who they praised for the diligence and care with which they conducted themselves as jurors.

“I think the recommendations they made were excellent and I can see how they will be very beneficial going forward,” Ken Starko said.

He added that his entire family is grateful to everyone who has reached out to them in their time of grief.

“Oliver, Caroline and I would like to thank all of the people who loved and supported Sidney in her short life and all of the people who continue to hold us up,” Starko said.