Sidney had a witnessed collapse from an accidental 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. Both the University and 911 had the means, time, and the opportunity to save her; both denied her the care that she needed until it was too late.
Naloxone, when given early in an opioid overdose, will reverse the effects of the opioid. CPR will keep the person alive for the few minutes it takes for the naloxone to work. Naloxone will not cause harm if given when it is not needed. No young healthy person should die from a witnessed collapse from an opioid poisoning.
The following is a summary of the failures of both the university response and the 911 operator. Click here for a detailed timeline of the events leading up to Sidney’s preventable death, including details of the 911 call.
SUMMARY:
In January 2024, two 18-year-old students had a witnessed collapse in a residence at the University of Victoria from an opioid poisoning, a completely treatable event in a young healthy person.
Student responders immediately called campus security as that is what students in residence at the University of Victoria are told to do for all emergencies. The student responders had no access to naloxone in the dorm.
Campus security, who are trained in CPR and carry nasal naloxone, showed up to find two unconscious ,blue students not breathing normally, and a third student impaired on fentanyl. Campus security waited 9 minutes after arriving to administer naloxone, and waited 12 minutes to initiate CPR, enough time for Sidney to suffer a catastrophic brain injury from lack of oxygen. Only her organs could be saved.
University of Victoria campus security never called 911 even though witnesses notified them the students were blue as early as 3 minutes after the collapse, and even though campus security arrived to an impaired student on the phone with 911. They left the impaired student to communicate with 911 for another 5 minutes after arriving on the scene.
With two blue unconscious teenagers on the ground, 911 took 3 1/2 minutes to determine the exact location on campus before even asking the reason for the call.
The 911 operator was told that there were two teenagers who had collapsed and had started seizing. Instead of dispatching immediately, the 911 operator first asked the caller multiple questions including questions about pregnancy, brain tumors, diabetes and strokes before dispatching emergency services. The 911 operator interrupted the caller’s description of the unconscious 18year-olds to ask if they were pregnant, missing the opportunity to learn that the students were blue.
It took more than 7 minutes for 911 to dispatch emergency services. As a result, the firefighters who came from the firehall across the street from the University took 15 minutes to get to Sidney’s side.
After 8.5 minutes, the 911 operator asked to speak with campus security and asked them to help assess Sidney’s breathing. The security officer told 911 that Sidney’s breathing was very faint and pretty shallow. 911 told the security officer not to say anything other than the word ‘NOW when Sidney takes a breath so she could count them’. After a long pause where you could only hear the other student’s intermittent loud obstructed airway sounds (coarse stridor/grunting) in the background, the security officer again conveys that Sidney’s breathing it is pretty faint. After 40 seconds of being unable to detect a breath, he switched out with the other security officer who complied with the 911 operator and only said the word NOW when he thought Sidney took a breath.
After this exchange,911 remarkably concludes that Sidney is BREATHING EFFECTIVELY. At that point, Sidney had been blue for 8 minutes, unconscious for 11 minutes and one security officer did not think she was breathing at all.
911 took 11 minutes before asking if the two unconscious 18-year-old students could have taken ‘something’. She waited another minute to ask if security had Narcan (naloxone). She then told the security officer to leave the phone with the two unconscious students to go find their friends to find out what happened.
Finally, when the student impaired on fentanyl admitted that there was a high probability that the students had taken something, the security officers gave naloxone at the direction of the 911 operator 13 minutes into the call, and approximately 10 minutes after the two unconscious 18-year-olds started turning blue.
After confirming a possible drug ingestion and giving naloxone, there were no questions about whether the students were breathing or breathing effectively, even though loud obstructive airway (coarse stridor/grunting/wheezing) sounds from the second student could clearly be heard in the background.
Instead, the 911 operator asked to be notified if the students became less awake.
Almost fifteen minutes into the call, security announced that he could not find a pulse on Sidney. They took another 20 seconds at that point to confirm that Sidney was really not responsive or breathing before initiating chest compressions. The fire department arrived moments later to find Sidney in full cardiac arrest.
Sidney suffered a catastrophic brain injury from lack of oxygen. She became an organ donor 5 days later. Her death was preventable. She was denied life-saving care by campus security and the 911 operator until it was too late.
The University of Victoria never notified Sidney’s family that she had suffered a cardiac arrest in their dorm and that she was brought to hospital in critical condition. A student bystander called Sidney’s brother, also a UVic student, to tell him Sidney was brought to hospital. Even though Sidney was taken to hospital at 7 pm when flights and ferries were still running from Vancouver, where Sidney’s parents live, they did not find out about their daughter until it was too late to get to her side that night.
DETAILED TIMELINE
(see above for shorter summary)
Preamble: In Basic First Aid, if a person is unresponsive and not breathing properly, CPR should be initiated immediately after calling for help. Delaying CPR can result in brain damage and death. Permanent brain damage begins approximately 4-5 minutes after breathing or the heart stops.
Ongoing since 2016: BC declared a public health emergency in response to an unprecedented number of opioid overdose deaths due to an unpredictable and highly toxic drug supply. The drug supply continues to be increasingly poisoned with fentanyl.
January 2023: BC decriminalized possession of opioids, cocaine, methamphetamine and MDMA for personal use for people over the age of 18. Students over the age of 18 can legally possess enough fentanyl to kill an entire auditorium of opioid naive individuals. Students who believe they possess recreational drugs such as ecstasy/Molly/MDMA or cocaine often possess drugs contaminated with fentanyl. Students who believe they have obtained a ‘pain pill’ or ‘study drug’ may have counterfeit pills that are contaminated with fentanyl.
Sept 2023: Orientation for students in residence
Students are encouraged to call campus security for all emergencies including medical emergencies. Campus security officers have OFA level 2 training (CPR), and carry naloxone (the life-saving drug that reverses the effects of opioids).
There is no orientation for students in residence about harm reduction from drug use.
Orientation in residence did not include information about the risk of the toxic drug supply in BC, what to do in the event of an overdose, how to recognize an overdose or where students can get naloxone for free on campus.
The University does not make naloxone available in dorms.
January 20, 2024: There was an opioid overdose on campus requiring naloxone from campus security, the weekend prior to Sidney’s overdose. The campus security officers working on January 23rd were not notified of the recent overdose on campus.
January 23, 2024: Three students were exposed to fentanyl in a dormitory at the University of Victoria. Two of them, including Sidney, lost consciousness and collapsed to the ground. Several students heard them collapse and immediately responded. They arrived to find two unconscious students on the ground and a third impaired student trying to drag one of the unconscious students into her room telling everyone they were sleeping. The student responders recognized the two students were unconscious, called campus security immediately, and asked someone to call 911. They did not initially realize that the third student was impaired on fentanyl; tragically it was the third student who called 911. While one student responder was on the phone with campus security, the other student responders placed Sidney and the second unconscious student in the recovery position. The impaired student persistently denied drug use, but according to witnesses it was apparent early on that she was impaired.
18:32:17
911 received a call from the student who was impaired on fentanyl.
The 911 operator took 3 1/2 minutes before even asking the reason for the call. The 911 operator spent most of that time establishing the address. The caller clearly and immediately conveyed the correct location, but it took another 3 minutes for the operator to clarify the building name, the spelling, the parking lot, to establish that there was no buzzer, and to find the building on a map.
18:32:19
The campus security dispatch officer received a call from a student responder who told campus security that there were two girls seizing. He clarified the location of the event and quickly dispatched two security officers to the scene. He offered to put the caller through to 911 but chose not to when she told him “one of the friends are on 911 already”.
He told the caller that he would stay on the line with her until security arrives, and to let him know if anything changed.
37 seconds later (18:34:50) the student responder states that the unconscious students are turning blue.
60 seconds later, the student responder states that their eyes were rolling back.
The dispatch security officer does not respond either time the caller updated him on the deteriorating status of the students. He did not call 911 and he did not notify the responding officers who were on route to the scene. He gave no advice or direction to the caller.
911 never received the information that both unconscious students are blue.
18:36
Two campus security officers arrive to two unconscious students. In the security officer’s report, it states that the two students: “presented as unconscious and both were in respiratory distress”. At some point, the second unconscious student began to gurgle so the security officer adjusted her head and “she began to breath irregularly in gasping breaths”.
Student responders describe the unconscious students thus:
The second student was “gasping for air and really jerking as well as shaking in a way that resembled a seizure.” “She continued to wheeze and gasp loudly and it occurred about every 30 seconds. And lasted for 30 seconds”
They thought Sidney was initially seizing: She was stiff for about a minute and one hand was shaking but this stopped when security arrived and then she remained still.
They described both students as blue.
This description is corroborated by a 5th student who arrived prior to security and saw their “collapsed pale, blue bodies.”
On arrival, security does not give naloxone or initiate CPR.
At the same time that the security officers arrive on the scene, the 911 operator finally asks the reason for the call.
The impaired student tells 911 that two students walked in and “they passed out on the floor, and I think they started seizing.”
911 confirms that they are not awake, and confirms that they are breathing and then 911 asks the caller to describe “What’s is going on? What do you see?” The caller is only given enough time to say “they’re both just lying on their sides, they’re just on the ground” before the 911 operator interrupts her description of the students to ask if the two students are pregnant or if they have been pregnant in the last 4 weeks.
The 911 operator then proceeds to ask multiple questions: “Are they diabetic?” “Are they an epileptic?” “Do they have a history of stroke or brain tumor?”
18:38:05
The 911 operator says: “So we need to do one at a time, their breathing diagnostics”.
The operator then asks the impaired student to say ‘NOW’ each time Sidney takes a breath. The impaired caller asks people in the room to help her count the breaths, but the 911 operator admonishes the caller and tells her that she wants the caller to do it. The caller is unable to follow her directions and is unable to do this properly.
18:39
There are loud harsh obstructed airway sounds in the background (coarse stridor/grunting) and the 911 operator asks “What’s that sound?”
The impaired caller says: “It’s one of the girls. She is – I think she is gulping at the mouth.”
(*** it is possible that she says: “She is – I think she is frothing at the mouth.”)
The 911 operator asks if it is a seizure and the impaired caller answers yes.
18:39:34
BC Ambulance dispatches the fire department and paramedics to the scene. Seven minutes have elapsed since the call to 911.
The operator tells the caller what not to do if the unconscious student is actively seizing, and she tells the caller to roll Sidney on her side and keep her lying down when she wakes up.
18:39:57
911 again asks the caller to “do breathing diagnostics” and asks her to say NOW when the caller observes Sidney taking a breath. The caller says “OK” followed by a pause where you can only hear obstructed airway sounds in the background. The 911 operator then abruptly changes topics and asks: “So what did security say about a muster point?”
The 911 operator then asks a series of questions about where the ambulance should meet security. The caller gives confusing answers, she is clearly not understanding the questions.
According to witnesses, security at this point attempts to get the caller to convey the muster point to 911.
18:41
Eight and a half minutes into the call and five minutes after security arrived on the scene, 911 finally asks to speak to security and one of the student responders hands the impaired caller’s phone to one of the security officers.
18:41:17
911 tells the security officer to help check Sidney’s breathing asking “Are you able to do that for me?”
18:41:26
Security officer #1: “Yeah, no I got slight breaths”
18:41:28
911 asks: “Okay I want you to say ‘NOW’ each time she takes a breath so I am going to count them”
18:41: 33
Security officer #1 replies: “Got you, yes, NOW”
18:41:38
911: “Next”
18:41:40
Security officer #1: “It’s very faint, pretty shallow”
18:41:43
911: “I want you to say now each time, nothing else so I can count them.” Security#1: “Yeah, you’ll have to hold on, okay?”
18:42:01
Security officer #1: “Yeah, no it’s pretty faint”
18:42:14
Security officer #2 offers to switch with Security Officer #1 who still can’t detect Sidney’s breathing. At this point, Security Officer #1 has not detected a breath for 41 seconds, and the previous breath had been described as very faint and pretty shallow. During the long pauses where he could not detect Sidney breathing, coarse grunting/stridor/wheezing of the second unconscious student could be heard in the background. Security office #1 switched off, and security officer #2 takes over.
18:42:40
Security officer #2: “Okay I am ready”
911: “All right. Say now each time she takes a breath”
Security officer #2 then proceeds to say the word ‘NOW’ and nothing else every four seconds for 16 seconds
18:43:03
911: “Ok she is breathing effectively”
**During both security officers’ assessment of Sidney’s breathing, you can hear loud intermittent obstructive airway sounds (coarse stridor/grunting/wheezing) from the second girl in the background. This continues until the end of the 911 call.
**The security officer’s report from that night, states that the initial security officer on the phone could not detect any breathing and the second security officer could only detect weak, shallow and irregular respirations. Neither security officer mentions that Sidney and the other student are blue
911 then confirms that neither student is awake
18:43:20
Eleven minutes into the call, 911 finally asks, “Is it a possibility that they have taken something?”
Security officer #2 answers that “it is unknown and we don’t know if either of them have any seizure condition either”
18:44:11
In the background you can hear a student responder ask the impaired student if they have taken anything and the impaired student responds, “not that I am aware of, but it is a possibility.”
18:44:23
Twelve minutes into the call, the 911 operator asks, “Does anyone have Narcan?”
Security responds that they have it.
911 confirms neither student is awake
18:44:39
In the background you can hear security officer #1 ask the impaired student: “Are you sure you guys didn’t do anything? You are not in trouble, we just need to know if you guys took…”
18:44:52
911: “Can we track down their friends who they were with?”
18:44:58
911: “Just leave the phone with the patients, and if you do find any further info….”
18:45:06
The impaired student finally admits “that there is a high probability that they have taken something.” Security officer #2 relays this information to 911. Thirteen minutes into the call, 911 instructs security to give naloxone.
18:45:20 to 18:45:47
The security officers administer nasal naloxone (Narcan).
Intermittent loud obstructed airway sounds (coarse stridor/grunting/wheeze) from the second unconscious student continue to be audible in the background. 911 does not ask any questions about the students’ breathing until after she learns Sidney has no pulse at 18:47:23.
18:46:29
911: “Just let them rest in the most comfortable position, wait for help to arrive, and I’ll just stay on the line here as long as I can. So please watch them very closely. Look for any changes. And if they become less awake or start getting worse, just tell me immediately.”
Security officer #2: “OK”
911: “Just don’t leave them alone until the paramedics are right there. Tell me when they are there with them.”
18:47:22
Security officer #2, referring to Sidney, “I don’t think I am getting a pulse on this one”
18:47:42
Security initiates CPR after confirming that Sidney is also not breathing and is still unconscious.
18:48
Fire arrives at the scene and they initiate bag valve mask and take over CPR. Soon after ALS paramedics arrive.
18:58
Sidney’s body is resuscitated but she has suffered a catastrophic brain injury from lack of oxygen. She is transported to hospital on life support and admitted to the intensive care unit.
The University of Victoria fails to notify Sidney’s family that their daughter had a cardiac arrest in their university dorm and she was brought to the hospital in critical condition. A student bystander contacted Sidney’s brother to let him know Sidney was taken to the hospital. By the time Sidney’s parents hear the news that night, there was no way of getting to the Victoria. As a result, Sidney’s brother sat alone in the ICU that night with his sister, and Sidney’s parents lost one of the few nights they had left with their child.
January 26, 2024:
Sidney is declared brain dead
January 29, 2024:
Sidney’s organs are retrieved and transplanted into 5 individuals.
After Sidney’s fatal fentanyl poisoning in the dorm on campus, the University of Victoria sent two emails to its students:
Summary of UVic email dated January 24, 2024:
To University of Victoria Residents,
“We are receiving reports that the unregulated drug supply in B.C. is unsafe right now. Residence Services and Campus Security Services want to share information with you to help prevent overdose and how to recognize an overdose.”
The email then provides links to safer substance use and supplies. It does does not mention there were three overdoses on campus in the preceding five days. They University does not mention naloxone in the email or make it more widely available in dorms or on campus.
Despite Campus Security’s failure to provide basic first aid, including administering CPR or naloxone in time to save Sidney when they showed up to her overdose, the University advises:
“If you or someone around you begins showing any signs of over-intoxication or overdose, call Campus Security or 911. If you are unsure, call Campus Security and we will come to help. Campus Security officers are highly trained medical responders and will provide a supportive and judgement free response. Campus Security also carry naloxone, which is an effective treatment for opioid drug overdose. Campus Security is available 24/7 at 250 721-7599. Please program this number into your phones.”
On January 26, 2024, the University of Victoria sent an email to all students:
“As many of you are aware, there is a concerning trend of unsafe drugs in BC. At a press conference on Jan. 24, BC’s Chief Coroner stated that nearly seven people a day died from toxic drugs in 2023 in BC. At UVic, The Student Wellness Centre, Office of Student Life, Residence Services and Campus Security want to share information with you to help prevent, recognize and respond to an overdose or over-intoxication”
The email provides information about how to use more safely and how to access harm reduction information and supplies including naloxone. Once again, the University does not mention that there were three overdoses on its own campus in the preceding week, including the fact one student (Sidney) remained in critical condition. They do not make naloxone more widely available in dorms or on campus.
Again, despite the deadly response of Campus Security, the email advises:
“If you or someone around you begins showing any signs of overdose or over-intoxication on campus, please call Campus Security right away. If you’re off-campus, call 911. Here on campus, our security officers are highly trained medical responders and will provide a supportive and judgement-free response. Campus Security officers carry naloxone and are available 24/7 at 250-721-7599.”
Ten weeks after Sidney’s death, Sidney’s parents were informed both security officers continued to work at the University of Victoria and the head of campus security believes the security officers did what they were trained to do.
Ten weeks after Sidney’s death, the 911 operator continued to work for BCEHS.
April 2, 2024:
Sidney’s family meets with Kevin Hall, president of the University of Victoria, who knew little of the details of Sidney’s death (click for details of the presentation). The family gave a detailed account of the timeline as corroborated by BCEHS and the 911 call transcript. President Hall promised a full investigation. As of May 14th, the family has not heard back from President Hall or representatives of the university about this investigation. The university did respond to a reporter’s questions that were sent to the university on May 2nd.
In the press release, the University of Victoria disputes the timeline described in this document. The time security gave naloxone and initiated CPR is in the 911 call record that is embedded with time stamps. Despite this, the university believes their security officers gave naloxone at 7 minutes after the call, 4 minutes after security arrived. Even though they are incorrect about this timeline, this would still not have been an adequate response. Brain damage starts about 4 minutes after breathing stops or becomes ineffective. Waiting 4 minutes to give naloxone, and waiting another 3 minutes to initiate CPR after arriving to two unconscious blue students, who had been down for 3 minutes, would likely lead to very serious harm or even death.
“Ensuring the safety of our community remains our top priority, especially amidst the pervasive threat of toxic drugs that are claiming the lives of youth at an alarming rate in our province.”
–Kevin Hall, University of Victoria President and Vice-Chancellor
“Our security officers are trained in first aid, with most officers—including those who attended to Sidney—trained in OFA level 2. They are not trained as emergency first responders or emergency medical professionals. Our officers responded immediately, and provided lifesaving first aid while waiting for emergency first responders to arrive. Our security officers met emergency first responders and got them to the location as quickly as possible. Although that day ended tragically, their efforts are commendable, and I am proud to work with such a caring team who show up every day to serve the campus community.”
–Jessica Maclean, Director, Campus Security
ADDENDUM:
Details on orientation for students who live in residence at the University of Victoria Sept 2023:
During orientation, students were encouraged to call campus security (CS) for all emergencies. There was no orientation to harm reduction from drug use. Orientation did not include any information about the risk of the toxic drug supply in BC. Orientation did not include what to do in the event of an overdose. Orientation did not include where to get naloxone for free on campus. Naloxone is not made available in dorms.
Orientation included an introduction to the community leaders (CL). CL’s do not require first aid training or naloxone training. CL’s are required to complete training in Sexualized Violence Prevention and mental health support.
The University of Victoria Community Living Handbook for students “outlines everything you need to know about living in your new home, including rights and responsibilities in the residence community”. It includes sections on safety and security as well as programming and Health and Wellness. They reference rules and regulations around alcohol and marijuana use and possession. The only reference in the handbook to other substances is “any possession or involvement, whether direct or indirect, in any illegal drug or drug-related activity is prohibited. Possession of drug related paraphernalia that is associated with the possession, use or trafficking of illegal or prescription drugs/medications is strictly prohibited.”
The Community Living Handbook describes some of the services at the student wellness center but there is no mention that there is a harm reduction center within it that can provide naloxone and drug testing.
None of the first-year students that we spoke to were aware that there was a harm reduction center on campus. Most did not know what naloxone is.
Further Details about Campus Security at the University of Victoria:
Students are encouraged to call campus security for all emergencies including medical emergencies. A CL poster on the floor where Sidney died specifies to call campus security first for all emergencies. We were told that the University of Victoria security officers have occupational health and safety level 2 training (first aid/CPA) every three years. They get naloxone training when they are hired. They have access to an AED and carry naloxone. They have no medical oversight, nobody reviews their medical responses. They do not debrief medical responses with anyone. There are no specific protocols on how to respond to an unconscious student or a suspected overdose. At the time of Sydney’s death, there was no protocol in place instructing security to contact 911 for life threatening emergencies.
The head of the University of Victoria campus security informed us that part of the justification for having security called for medical emergencies is to be able to get 911 on campus quickly and direct them to the proper location. Even though students called campus security immediately, it took the 911 operator 3.5 minutes to determine the location on campus before asking the reason for the call. It took 15 minutes for the firefighters across the street from the campus to arrive to our daughter’s side and critical information about the student’s turning blue was only conveyed to campus security dispatch who did not convey that information to 911.
Nasal Naloxone in Canada:
In 2018, easy-to-use nasal naloxone was made available for free to anyone in Ontario and Quebec. In 2019, the NWT followed suit. That same year, when interviewed by CBC, the harm reduction lead for the BCDC denied that injectable naloxone kits are difficult for users to administer, even though a paper she co-authored the same year “acknowledges difficulties in properly training and preparing ‘needle-naive’ individuals to use injectable naloxone.”
Despite having the highest opioid death rate in the country, in 2024, BC continues to only supply injectable naloxone to the general public.
What Happens in an Opioid Overdose:
During an opioid overdose a person may become unconscious and may stop breathing or have difficulty breathing adequately. Naloxone can reverse the effects of an opioid overdose and get a person breathing again. If a person is unconscious and not breathing properly, CPR will keep them alive while waiting for the effects of the opioid to wear off or for the effects of naloxone to kick in. If a person stops breathing and CPR is not initiated quickly, the brain will suffer irreversible brain damage and the heart will eventually stop from the lack of oxygen. Irreversible brain damage begins in about 4 minutes. A witnessed collapse from an opioid overdose in a young healthy individual is easily treated and should be 100 percent survivable. Quick action with naloxone and CPR is key to survival. Naloxone will not cause harm if given when it is not needed.
About Fentanyl:
Fentanyl is a synthetic opioid.
Miniscule amounts the size of a couple of grains of sand can kill an opioid-naive individual.
Over 90 percent of drugs in BC are contaminated with fentanyl.
Many people dying from fentanyl did not know they were consuming fentanyl.
In addition to the typical signs of an opioid overdose, fentanyl can cause stiffness and jerking (a study at Insite in Vancouver in 2018 found 25% of overdoses had stiffness and jerking).
How to Recognize an Opioid Overdose (Alberta Health Services):
Signs & Symptoms of an Overdose
- Slow or no breathing
- Unresponsive to voice or pain (can’t wake them up)
- Pale face
- Blue lips or nails
- Gurgling or snoring sounds
- Choking or vomiting
- Cold and damp skin
- Narrow (tiny) pupils
- Stiff body or seizure-like movement
The sources of the details and times of the events of January 23, 2024:
A recording of the BCEHS 911 call with embedded time stamps.
The University of Victoria campus security tapes and associated time stamps. These tapes include the call to campus security from the student responder.
An internal University of Victoria Campus Security report titled SO response, dated January 23, 2024.
BCEHS paramedic report, and email communication with BCEHS.
Interviews/emails/texts/written accounts from the five students who witnessed and responded to Sidney that night, including the student who called campus security and the student who met the first on-scene firetruck.
The fire incident report and communication with the deputy fire chief.
We do not have the security report that was sent to the coroner, or the internal report written by the other security officer but we have asked for these via a Freedom Of Information (FOI ) request.
