- David Eby
- Bonnie Henry
- Adrian Dix
- Lisa Beare
May 15, 2024
In January 2024, our daughter Sidney died after suffering a cardiac arrest due to a fentanyl poisoning in a dorm room at the University of Victoria. Catastrophic failures by both the University of Victoria and the 911 operator led to her preventable death.
I am Sidney’s mother and I am writing this letter on behalf of our family. I have worked in this province for the last 25 years as an emergency physician. As you are aware, no young healthy person should die from a witnessed collapse from an opioid poisoning. It is easily treatable. Naloxone, when administered quickly, reverses the effect of an opioid overdose. Simple CPR will keep the person alive while waiting for the naloxone to work or waiting for help to arrive.
Our daughter’s death was preventable. Witnesses heard Sidney and another student collapse and did exactly what they were told to do for emergencies at the University of Victoria. They called campus security immediately. Campus security never contacted 911. The only person on campus to contact 911 was an impaired student who had difficulty following simple instructions. Campus security showed up in about 3 1/2 minutes, with enough time to save our daughter. Sidney and another student were unconscious and blue when campus security arrived. The security officers were trained in CPR and carried nasal naloxone. They denied her the lifesaving care she needed until it was too late. They administered naloxone 9 minutes after they arrived and started CPR almost 12 minutes after arrival. Sidney was an organ donor five days later. The other unconscious student had maintained gasping respirations approximately every thirty seconds which was enough to keep her alive until she finally received naloxone. Even the 911 operator waited more than 10 minutes when dealing with two unconscious 18-yearolds in a university dorm before asking if they could have taken drugs, and 12 minutes before recommending naloxone. Because they were dispatched late, the fire department, which is directly across the street from the campus, did not arrive at my daughter’s side for 15 minutes. At that point, Sidney was in full cardiac arrest and only her organs could be saved.
The phone was the only tool available to the students who responded and wanted to help two unconscious young people in their dorm. Living in residence at the University of Victoria, these students had no access to naloxone in their dorm, nor had they received orientation to the toxic drug supply in BC or how to recognize or treat an overdose. Having gone to high school in BC where CPR is not mandatory in the school curriculum, they were not trained in CPR. They responded exactly as the university told them to respond to an emergency: they called campus security. In the end, these students suffered the trauma of witnessing another student die when campus security showed up and failed to act.
Opioid toxicity is the leading cause of death in the 10-29 age group in BC. This province has the most toxic drug supply in the country. As Bonnie Henry points out in ‘Stopping the Harm’, overdose deaths are affecting people who use drugs for the first time and people who only use drugs occasionally. In BC, teens and young adults can legally possess and carry enough fentanyl to kill an auditorium of opioid-naive students. Both the increasingly toxic drug supply, as well as the decision to decriminalize possession, should have been independent triggers for the government of BC to put measures in place to protect our youth.
As you are aware, teens and young adults are at high risk of sometimes making poor choices and taking risks. This is developmentally normal. With the current drug supply, it puts them at high risk of a toxic drug death. Tragically, young people today who are offered a pill or a powder or something to smoke, may inadvertently consume fentanyl.
Young healthy people suffered significant harms from the public health mandates during the COVID public health emergency. We closed their schools, we banned them from congregating with friends and we shut down their recreational and sporting activities. Teens and young adults were at minimal risk of death from COVID; these extreme measures were for the benefit of the greater population. During the public health emergency from opioid toxicity, our youth are at risk of lethal harm, yet the BC Government has instituted no measures to protect them.
Eight years into this public health emergency, how is it possible for our daughter to have a witnessed collapse from an opioid overdose at 6:30 pm on a Tuesday evening in a university dorm and die? Our daughter’s death was completely preventable. Systemic failures on the part of both the province of BC and the University of Victoria contributed to Sidney’s death. BC must act to protect this population, the young, first-time or occasional drug users who are at high risk of death if accidentally exposed to fentanyl. Below are seven steps that would help protect them:
- MAKE CPR AND NALOXONE TRAINING MANDATORY IN THE HIGH SCHOOL CURRICULUM
CPR is mandatory in the high school curriculums in Ontario, Quebec and Manitoba. Why is BC so far behind? This province has refused to make CPR a mandatory part of the high school curriculum. The ACT Foundation will implement the CPR and naloxone training for free:
Unless BC makes CPR and naloxone training part of the curriculum, not all students will benefit. A statement by the education ministry in 2022 said: ‘it’s up to each school district to determine the delivery of any programs, including whether to stock naloxone kits or train teachers how to use them’.
This is unconscionable. None of the students who witnessed my daughter’s death were from a school or school district that chose to implement CPR training. Why should a school district get to choose who gets to learn how to stay safe and save a life?
2. MAKE EASY-TO-USE NASAL NALAXONE WIDELY AVAILABLE FOR FREE IN BC
Naloxone kits in BC come with naloxone in a glass vial. The lid must be broken off, the drug drawn into a syringe through a long thin needle, and then the needle injected into the overdosed person. This may be a reasonable option for a person who uses intravenous drugs, but this is a prohibitive approach for most of the population, especially young people.
Nasal naloxone is a simple-to-use, one-step nose spray. Since 2018, citizens of Ontario and Quebec have been able to walk into a pharmacy and get nasal naloxone for free with no questions asked. One dispenser can easily fit in a jacket pocket when going out. The simple 5 minute video will teach you how to recognize an overdose and when and how to use it:
Naloxone Care Video
How can BC be so far behind Ontario and Quebec when our toxic drug crisis is much worse? Public Health consults with people with lived experience when making policies, but the population of young people who die from using drugs for the first time have a lived experience of about ten minutes. You cannot consult with those young people because they die the first time they are exposed to fentanyl. It is just as important to protect this population as it is to protect the opioid-dependent population. The province could continue to supply the needle naloxone for people who are experienced using needles or prefer it, but young people, and those who do not want to use needles, and their friends, family, co-workers and teachers deserve widely available, free, easy-to-use nasal naloxone without intimidating needles. Sidney’s preventable death underscores how crucial it is to put naloxone in the hands of many. Injectable naloxone is not a reasonable option for this.
A recent study out of Waterloo shows that distributing nasal naloxone is cost effective and saves more lives:
See Waterloo news regarding nasal naloxone study
Governments in other jurisdictions have secured deals to make this more cost effective:
See California news and initiatives
3. MAKE NASAL NALOXONE KITS/BOXES WIDELY AND EASILY ACCESSIBLE IN SCHOOLS AND ON CAMPUSES IN BC
Sidney would be alive if nasal naloxone had been available in the dorm where our daughter died and if the students had been educated on how to recognize and treat an overdose. The students who responded were competent and motivated to help, but they were not given the tools they needed to help save her life. Their only option was to call for help. As you know, time is crucial in treating opioid toxicity. Why risk having to wait for campus security or paramedics when a competent student may be nearby and willing to help? In our daughter’s circumstance, it was deadly for campus security to be the only people with naloxone.
Carleton University is far ahead of the curve in protecting its students. They have an excellent system set up with nasal naloxone boxes in all residences and several buildings on the main campus. They are expanding this program to reach a total of 27 boxes dispersed across campus:
See Carleton Naloxone Kits on campus PDF
This type of emergency box containing easy-to-use nasal naloxone should be set up in all dorms and main buildings on BC campuses and in all BC high schools and community centers where people between the ages of 12 and 24 congregate. You can build your own, or get them at:
https://bereadyhealthcare.com/shop/
4. MAKE ORIENTATION AND TEACHING ABOUT THE TOXIC DRUG SUPPLY AND HARM REDUCTION MANDATORY. USE LANGUAGE THAT STUDENTS WILL UNDERSTAND AND RELATE TO
The language around harm reduction and the availability of that knowledge must change for young people in BC. The government, most universities and most high school are doing poorly at educating students about the toxic drug supply and overdose prevention, with deadly consequences. Not a single student that I spoke with knew the meaning of the term ‘harm reduction’ and none were aware of the harm reduction center on campus at the University of Victoria. Educators need to speak with students using language that they understand and use. There may be value to changing terminology to destigmatize people who use substances, but the consequence of that change in language can’t be that young people don’t hear or understand you.
Orientation events and orientation material at the University of Victoria, including, the Community Living Handbook and the New Student Handbook, did not include information about the toxic drug supply in BC, how to stay safe around potentially lethal drugs, and how to recognize or treat an overdose. Many students I spoke with were unaware they could be exposed to fentanyl in pills, powders or by smoking substances. Most students did not know about naloxone. In BC, you can possess fentanyl, MDMA/ecstasy, and cocaine for personal use. If we are sending that message to a young person, we owe it to them to educate them. Let them know that whatever substance they believe they possess may be contaminated with fentanyl, and that tiny amounts can kill them. Give young people information about, and easy access to, nasal naloxone. That way they can protect themselves and each other in the event that their poorly developed prefrontal cortex makes a lousy choice and decides to try ‘ecstasy,’ or a ‘stimulant’ that might help them study. This information is much more relevant to most students than knowing where to get safe injection supplies.
Our province cannot rely on all high schools and universities to do this voluntarily. The University of Victoria did an abysmal job of this. Even after three overdoses on campus within five days, one with deadly consequences, the University did not notify its staff and students about the problem with overdoses on its own campus.
The program at Carleton University is the poster child of how to do this right. Click on their substance use health tab and you will find a wealth of straight forward information. Dillon Brady, Carleton University’s Manager of Student Conduct and Harm Reduction, has partnered with Mark Barnes of Naloxone Care and they have trained thousands of Carleton staff and students and provided direct access to nasal naloxone (Narcan). Carleton has multiple table fairs every year in high traffic areas with all kinds of information on how to stay safe with direct access to nasal naloxone training on the spot. Not cumbersome, intimidating needle naloxone, but easy-to-use Narcan nasal naloxone spray. This program is so well received that professors invite Mr. Barnes as a guest lecturer to teach and train entire classes of students during class time. Carleton has not had an overdose death on campus. This program was developed in 2019 as a preventative measure to keep students safe.
5. THE GOVERNMENT NEEDS TO REVIEW THE UNREGULATED ‘PARALLEL MEDICAL SYSTEM’ IN BC UNIVERSITIES
What happened to our daughter when campus security responded to her medical emergency at the University of Victoria is unfathomable, particularly in a province with a declared public health emergency for the fentanyl crisis. Students are told to call campus security for all emergencies. The student Wellness Center website, under Emergency and 24-Hour Contacts states, “If you need Immediate Help contact 911 or Campus security.” That statement implies that campus security and 911 are equally qualified to help. Three days after the catastrophic response to our daughter’s overdose, the University of Victoria sent an email to the student body advising: “If you or someone around you begins showing any signs of overdose or over-intoxication on campus, please call Campus Security right away.” In that email they also stated, “Here on campus, our security officers are highly trained medical responders.” Those medical responders had literally just deprived our daughter of lifesaving care when they responded to her overdose. They showed up to find two unconscious, blue students in one of their dorms and waited until one was severely brain injured from a lack of oxygen and almost dead before giving naloxone and initiating CPR.
How can a BC University encourage students to call campus security instead of 911 when campus security’s emergency response contributed to a student’s death? How can a university in BC refer to their staff as highly trained medical responders when clearly, they are not?
From what we have been able to understand about the University of Victoria at the time of Sidney’s death, campus security had no medical oversight, no protocols in place for how to respond to common medical emergencies including an unconscious student, they had no ongoing training and they did not perform debriefs or reviews after a medical response. Yet administrators at the University continued to encourage students to call campus security for medical emergencies.
Who in this province is regulating medical responses at universities? The University of Victoria is not the only University in BC to encourage students to call campus security for medical emergencies. These institutions must be better regulated. The BC government must establish standards and protocols for emergency responses on university campuses. First and foremost, universities must be mandated to always contact 911 for medical emergencies. This cannot be left up to an impaired student, as it was in the case of our daughter’s death. There must be a better coordinated approach between BCEHS and campus security to provide a timely, safe approach to a critically ill student. When there were two students in dire need of emergency services, 911 took three and a half minutes to figure out the address at the university before even asking the reason for the call.
6. PUBLIC HEALTH SHOULD BE NOTIFIED OF OPIOID-RELATED OVERDOSES IN HIGH SCHOOLS AND ON CAMPUSES
There is no real time surveillance and warning system in place to track overdoses and opioid deaths in young people in schools and on university campuses, despite opioids being the leading cause of death in teenagers and young adults. Campus security should be required to notify public health of overdose events so that real time surveillance can be used to keep students informed and to keep our youth safe. Similar systems should be put in place in high schools and campuses throughout the province so young people are aware of toxic drug supply in their immediate networks and communities. The University of Victoria’s response to Sidney’s death demonstrates that you cannot rely on a university to share information about these dangers on campus.
7. A CORONER’S INQUEST MUST BE HELD TO REVIEW THE OVERWHELMING FAILURES IN SIDNEY’S DEATH.
It is in the public interest to hold a coroner’s inquest to review the circumstances of Sidney’s death and make recommendations to prevent lethal harm to opioid-naive youth who may occasionally experiment with drugs, particularly in post-secondary institutions. They must also explore the disastrous response from the 911 operator which we have not addressed in this letter.
Fentanyl may have killed our daughter, but the response by the University of Victoria and the province’s lack of harm reduction strategies targeted to this population allowed her to die. With the level of toxicity in the drug supply in BC, we must do more to protect our youth. BC has either forgotten about or consciously chosen not to protect this population. We cannot let this happen to another young person.
We have extensive documentation that corroborates the details in this letter, including the 911 call record. Please contact me if you wish to discuss them. You can also access a detailed timeline outlining the catastrophic failures resulting in the death of our daughter at this link.
We strongly urge you to implement these seven recommendations and look forward to hearing back from you on this.
Sincerely,
Caroline McIntyre and Kenton Starko
