1. BC Ambulance had the the location of where the 911 call originated, accurate to within 14 meters, within 7 seconds of the 911 call taker receiving the call. Yet the call taker was unable to expediently use that information.
   BC Ambulance had the “Common Place Name” and associated address, everything the call taker needed to for ambulance dispatch, within 46 seconds of the start of the call.
   Yet it took the call taker 3 1/2 minutes to move past the location determination phase of the emergency call.
2. The call taker failed to execute the breathing diagnostic tool correctly. This was seen multiple times throughout the call.
3. The call taker was inappropriately asking questions of the caller like “what did security say about a muster point”. BC Ambulance was required to call UVic campus security to determine the muster point. A student would not be aware of this information.
4. Naloxone delivery was not recommended until after the 3rd victim on scene admitted that drug use was a highly likely scenario. Narcan has no dangerous side effects. That is, if a victim has not consumed opioids, there are no negative side effects of Naloxone.
5. Once an overdose was discovered and naloxone was administered, there were no further checks on the breathing status of either patient. Naloxone takes minutes to be effective. A victim may not be breathing while waiting for the naloxone to take effect. Breathing must be monitored and, if necessary, supported with rescue breathing and/or chest compressions.
6. The protocols from the 911 system are provided by the US company “Priority Dispatch”.

The US company, the International Academies of Emergency Dispatch (IAED), a partner company of Priority Dispatch, reviewed the call and came to the conclusion that the call taker “performed very well”.

The response from BCEHS shows little insight into what went wrong.