On June 4th, we sent a letter to UVic President Hall, the Board of Governors, and the Senate in response to their false, misleading and egregious statements made in the media.
Click here to see the letter we sent on June 4th.
June 4, 2024
To: President Hall, Members of the UVic Board of Governors, Senate, and Associate Deans
We are writing to express our deep concern about statements in the media from University of Victoria officials regarding the events of January 23, when two students had a witnessed collapse from an opioid poisoning in a University of Victoria residence. We write to you asking that you publicly retract those false, misleading and egregious statements made to the media. Sidney McIntyre-Starko died because she did not receive the basic, life-saving first aid she deserved. In this letter, we will outline some of the events of January 23rd, what President Hall clearly knew about those events, and why the statements made by University officials in the media are false and/or misleading.
We met with President Hall and Christina Harris for two hours on April 2, 2024 and gave them the full details of the events of January 23, including the catastrophic response from campus security. At the end of the meeting, they were fully aware of the correct timeline of events as detailed by both UVic timestamps and timestamps from BC ambulance and the 911 call. These timestamps and timeline are important. When a person stops breathing or is breathing inadequately, minutes will determine whether the victim lives or dies. Distorting any of those times by minutes changes the entire appearance of the response.
During that meeting, we explicitly detailed the events, we explained what failures occurred and we explained the basic first aid steps that should have been followed to save the life of a teenager who collapsed in campus residence building. Although Caroline McIntyre is a physician, we explained how the appropriate response from security required only basic first aid to save Sidney’s life. We explained the steps of basic first aid using a simple red cross poster. They were informed that during an opioid overdose, a person stops breathing or their breathing becomes slow and inadequate. With basic first aid, simple rescue breathing or chest compressions would keep a person alive.
As of April 2nd, President Kevin Hall and Christina Harris were fully aware that campus security officers arrived in time to save Sidney’s life, yet Sidney was not given life-saving first aid and died several days later. University of Victoria security officers left our unconscious, dying child on the ground without providing CPR for 12 full minutes, and only initiated chest compressions when it was too late. President Hall and Christina Harris were fully aware that campus security waited for Sidney’s heart to stop and for her to suffer a devastating brain injury that would eventually kill her, before they initiated CPR. They were aware that, even after giving naloxone 9 minutes after arriving to two unconscious students who were barely breathing and were blue from lack of oxygen, campus security still failed to support either students breathing.
President Hall and Christina Harris were fully informed that in basic first aid, CPR should be initiated when responding to an unconscious person who is not breathing or not breathing adequately. They were fully aware that campus security records prove both students were unconscious and blue from lack of oxygen when campus security arrived. From the information they received in the April 2nd meeting, they were well aware that the security officers’ actions were completely inadequate.
The director of campus security, Jessica MacLean, has been aware of all of these facts prior to April 2, 2024.
– UVic Quote in the media:
“Although that day ended tragically, their efforts are commendable”
The University of Victoria security officer’s efforts resulted in the preventable death of one of your own students. This is not commendable, it is an absolute tragedy.
– UVic Quote in the media:
“Our officers responded immediately and provided life-saving first aid while waiting for emergency responders to arrive”
In lifesaving first aid, one would never respond to an unconscious person, blue from a lack of oxygen, who is barely breathing or not breathing at all, and not initiate CPR immediately. Waiting for Sidney to suffer severe brain damage and waiting for her heart to stop prior to starting chest compressions, would never be considered lifesaving first aid. Your security officers were in the room with our dying child for close to 12 minutes before they started chest compressions, 20 seconds prior to the fire department arriving. Their efforts were neither life-saving nor commendable.
University of Victoria security officers eventually gave naloxone but did not initiate rescue breathing or chest compressions even when they finally understood this was an overdose. Watch the short naloxone training videos on ‘towards the heart’ website that very clearly explain the need for either rescue breathing or chest compressions during an overdose even if naloxone is given. https://towardtheheart.com/naloxone-training. No first aid responder should administer naloxone and then not support a victim’s breathing if they are not breathing adequately (rescue breathing or chest compressions would work). The victim could suffer brain damage and die, as Sidney did. Your security officers must be aware of this. They must not be told that their response was lifesaving or commendable. If they believe this to be true, they may do it again and another student will die.
– UVic Quote in the media:
“These efforts didn’t save Sidney’s life, but they did save the life of another student that night”
As we informed President Hall, Christina Harris and Jessica Maclean, a witnessed collapse from an opioid poisoning in a young healthy person is 100 percent survivable. A survival rate of 50 percent is disastrous. University of Victoria security officers also failed to support the breathing of the second unconscious student who was blue from lack of oxygen. If she did not have occasional spontaneous gasping respirations to help her survive the catastrophic first aid response, she would almost certainly have died alongside Sidney.
– UVic Quote in the media:
“The security officers followed the protocols of their first-aid training, starting with a scene assessment, triaging and then into emergency first aid, such as vital checks, administering naloxone and then CPR. They made every effort, within their areas of expertise and training, to save Sidney’s life.”
As we informed President Hall, Christina Harris and Jessica MacLean, no basic first aid course on the planet teaches a person to wait 12 minutes to initiate CPR when they come upon a person who is unconscious, blue and not breathing properly, or not breathing at all.
Scene assessment in basic first aid involves assessing the environment for any potential hazards, such as downed power lines or spilled chemicals. This scene assessment would have taken about 10 seconds. There were two blue unconscious students on the ground in one of your own dorms, a third stoned docile student sitting on a bed speaking to 911 and 4 cooperative sober student bystanders who immediately stood out of the way when security arrived.
Triaging these patients would have taken another 10 seconds. There were 2 security officers and two unconscious students, one for each of them to attend to. Nobody else on scene was in medical distress. As for vital checks, that should have taken less than 30 seconds to ensure the students were not responsive or breathing properly. By everyone’s account, including your own security audiotapes and records, the students were both clearly unconscious and were already blue from lack of oxygen when UVic campus security arrived.
Overall, scene assessment, triaging and ‘vitals check’ would easily be accomplished in under a minute. Yet it took 12 minutes for your security officers to start CPR. Irreversible brain damage starts around 4 minutes. These security officers could not possibly have been following any first aid protocol or training. Even Kevin Hall at our meeting on April 2nd said “12 minutes is too late, to a layperson like myself, absolutely.” And Christina Harris said: “That’s not how I would have responded, so I see that as a problem.”
Yet five weeks later, the UVic press release called those efforts commendable.
– UVic Quote in the media:
“the university had shared all of its findings with the family.”
Despite a preventable death occurring on his campus 10 weeks prior, President Hall informed us that he and Christina Harris were unaware of most of the information that we provided at the April 2nd meeting. He promised he would look into multiple issues that we raised and Christina Harris ensured us we would receive the documents that we had requested. Eight weeks later we still have not received those documents. The only communication we ever received from President Hall’s office after that meeting was a response to our own follow up email:
‘We are reviewing everything we heard from you and appreciate your emails. We will be meeting with senior leaders and will be back in touch when we have information to share.
Though we know that we can’t understand the magnitude of your grief, we would like to share our condolences once again — and our commitment to proactively engage in reflecting on and learning from this tragedy.’
The next communication we received from President Hall was via a press release to Post Media five weeks later. Although Kevin Hall had been fully informed of the correct timeline, in that press release, the university supplied an incorrect timeline of events to Post Media and stated their officers’ efforts were commendable. In that media release, the university shortened their response time to initiating chest compressions by nearly five minutes . Remarkably, UVic officials failed to recognize that even the sequence of events in their incorrect timeline would not have been compliant with basic protocols in first aid. After their timeline of events was publicly proven false, UVic officials persisted in stating that their officers followed protocols of first aid training when clearly, they did not.
– UVic Quote in the media:
“Following this tragic event, we issued a campus wide notice to help prevent future harm to members of our campus community”
This campus wide notice did not mention overdoses at the University of Victoria. Jessica MacLean informed us that she, with representatives of student life, residence services, student wellness and the university communications team came together to create that notification. That group of UVic employees made an active choice not to mention toxic drug overdoses at the University of Victoria that had caused serious harm. They only mention toxic drug supply in British Columbia, which, in 2024 would not be news to anyone.
Despite repeated encouragement by both our family and senior student community leaders in residence, the university made the choice not to notify its staff and students of deadly overdoses on its own campus.
– UVic Quote in the media:
“security officers at the university receive occupational first aid training at level two and certification beyond what is required by the government”
This statement is technically correct but misleading. The government has no requirements for universities to protect students. The level of training and certification mandated by government at universities is exclusively based on the number of employees as outlined by WCB, and the number of students does not even factor into the equation. It is up to each university to develop its own medical response program for students without the help of government regulations.
Having no government standards, does not imply that the university of Victoria has no duty of care to its students. Campus wide communications describe UVic security officers as ‘highly trained medical responders’ and your website claimed they have ‘excellent first aid training’ and that ‘many are also trained paramedics’ (that false statement was finally removed 4 months after Sidney’s death after we brought it to the attention of the Premiere , the Minister of Post-secondary Education and also posted it on social media.)
Despite lack of government regulation or mandates, many universities have well developed programs for student safety. UBC Vancouver has emergency naloxone boxes in all their residence buildings. Their campus is covered in AED’s with an interactive map https://maps.gis.ubc.ca/webmaps/aed/ explaining where to find them and an explanation on their website how to use them. UVic has no naloxone in dorms. UVic removed naloxone that senior student leaders placed in dorms in response to Sidney’s death. The location of AED’s at UVic is not posted anywhere online other than to mention that you have them in your security vehicles.
It appears to us that UVic is using a lack of government standards to somehow justify why it has a system in place that left an unconscious blue student on the ground to die instead of providing her with the very basic first aid response that she deserved. You have 22,000 students on your campus, and thousands in residences. It is up to the University of Victoria to provide an appropriate safe first aid response, especially when you promote and encourage calling campus security for emergencies.
The security officers performed as well as the University of Victoria supported them to perform. With no ongoing training or protocols in place for common medical emergencies, they were doomed to fail. The university does not even debrief after serious medical emergency responses. The University of Victoria had an overdose on campus the weekend prior to Sidney’s overdose, and the university did not even share that information with other security officers so they could review the presentations and treatment of an overdose.
Two and 1/2 weeks after a death from an overdose on campus, the director of campus security had not debriefed her officers about this deadly incident until we implored her to do that. Without debriefing her officers, how could the director of campus security possibly support her staff’s education and training to prevent it from happening again?
We ask that the senate and board of governors review Kevin Hall’s leadership in dealing with the University’s catastrophic response to Sidney’s preventable death, as well as his, and the university’s, lack of integrity in dealing with our family and the media.
In addition, given Jessica MacLean’s continued belief that her officers followed protocols of first aid training when they denied our daughter basic CPR for 12 minutes while she lay dying in a UVic dorm, MacLean should be removed from the role of director of campus security. We believe it is dangerous to have a person with these beliefs in charge of a campus first aid program. If the director of UVic’s first aid program cannot understand and learn from the failures in the response to Sidney’s death, your university may deny the next student whose life depends on an adequate first aid response on your campus.
In addition, we request the Board of Governors and/or the Senate force university officials to make emergency nasal naloxone easily available in student residences. In statements both to us and to the media, the university continues to refuse to make naloxone any more widely available then it currently is on campus. The provincial health officer Bonnie Henry has given her full support to all the recommendations in our open letter including providing naloxone in residences. With a recent death from an opioid poisoning in a UVic residence, and the backing of the provincial health officer, it is absolutely indefensible that the university continues to refuse to provide this life-saving medication to your students living in residence.
From Bonnie Henry letter we received, May 24, 2024:
“I want to express my full support for each of the measures you recommend to prevent toxic drug deaths in BC. Your insights and recommendations for comprehensive overdose prevention education, enhanced harm reduction, and meaningful student support are evidence-based solutions that will save lives in this province. I am particularly distressed at the inconsistencies in education about the toxic drug crises and access to naloxone in post secondary institutions that you have identified.”
We also request the board of governors and/or the senate launch an independent investigation into a number of concerns conveyed to us by University of Victoria community leaders (CL’s), a number of whom have contacted us since Sidney’s story was published. A number of them have told us that they were informed by their superiors that CLs could not speak to friends, family or other students about Sidney’s death ‘because of the family’s confidentiality wishes.’ And that ‘the school was doing what they could to encourage Sidney’s parents to release the information about their daughter’s passing, but that it was proving very difficult’ If these statements are true, university employees intentionally lied about our family’s wishes, which would suggest a pervasive disregard for student safety and well-being in an attempt to cover up a death from an opioid poisoning on UVic campus. We have asked repeatedly for the university to warn the campus community that there were serious overdoses on campus. A CL also told us that she had been informed by her supervisor that Residence Life had been trying to get UVic to send out an email to students about the unsafe drug supply in Victoria, but that UVic did not want to as it would impact the school’s reputation. That email was only released after Sidney’s death, and it only referenced toxic drugs in British Columbia not in Victoria or at UVic. Once again, if this is true, it would suggest a pervasive disregard for student safety and prioritizing of the school’s reputation. If this is the culture at UVic, you must remediate this. The president’s office ,the AVP of student’s affairs and the director of campus security have proven they cannot be trusted to do such an investigation.
Finally, we would like to know why the Provost contacted President Hall on January 23rd to notify him of the ‘incident on campus’, yet she did not ensure someone from the university contacted our family. Sidney was brought to hospital with no ID and was left for several hours in the emergency department as ‘unidentified patient X’ with no family at her side. We were deprived of one of the remaining nights we had left with our child, her brother was left to sit alone through the night with Sidney in the ICU when he finally found her. The university and the president’s office have not had the decency to respond to us about this and we deserve an answer.
The Provost must explain why she called Kevin Hall that night and did not call us when Sidney was taken from the university by ambulance, on life support, after suffering a cardiac arrest in one of your residences. What is it about the culture at the University of Victoria where informing the president about Sidney’s cardiac arrest was deemed important, but telling her family was not?
A coroner’s inquest will not be held until sometime in 2025. The university must act now to protect its student’s. We remind you that you are a public institution who has a duty to your students and to the public. Protecting your reputation is not more important than doing what is right and what is necessary to protect your students. We believe your response, both to our family and to the media, is more reflective of the university’s desire to protect its image than a desire to learn from this deadly incident and make the necessary changes to provide a safe campus for its staff and students.
We are willing to meet and explain or clarify anything that you do not understand. We have documentation to back up all statements in this letter. The only thing we will not share yet are the emails from the CL’s as they have asked that we keep them confidential for now. If you can guarantee an independent investigation where their employment is guaranteed, we will reach out to them and ask if they will speak to you.
You can find a summary of our presentation to Kevin Hall and Christina Harris here.
You can find a timeline of Sidney’s death here.
You can find a copy of our open letter here.
We were unable to get the email addresses of the student members of the senate so we ask that this letter be forwarded to them.
We are forwarding this letter to the media outlets who quoted from the University of Victoria Media releases or interviews. We are also forwarding to the Minister, the Deputy Minister and the opposition critic of post-secondary education.
We will end this letter with a quote from one of the student responders. The university of Victoria would not have this quote in their records as the university has refused to interview any of the student bystanders who responded to the scene. In this quote, the student bystander describes Sidney’s appearance when UVic Security officers were in the room for 12 minutes not providing either rescue breathing or chest compressions:
“She was just limp and very clearly blue. Like, I don’t think I’ve seen somebody that colour before. It was very obvious.”
The security officer’s efforts were not commendable. They did not follow the protocols of first aid training. They denied our daughter life-saving first aid. The University of Victoria must prevent a similar tragedy from happening on your campus. Student safety is more important than your reputation.
Caroline McIntyre and Kenton Starko
Sidney’s parents
To this date, UVic has not corrected nor retracted the false statements they made to the media.
On April 2nd, our family met with Kevin Hall, the president of the University of Victoria.
Click here to see the presentation made to President Hall of UVic.
Outline of Presentation to Kevin Hall, President of UVic, April 2, 2024.
Two students overdosed in a dorm room, in residence here at the University of Victoria, on January 23rd 2024, and our daughter Sidney died from that overdose.
We would like to explain to you our understanding of the events of that night, it is very important to us that you know and understand the details of what happened. Understanding what happened is the only way that you can prevent this from happening again. Protecting your students must be your primary concern here on campus.
Before getting to Sidney’s death, can I ask you if you understand what happens in an opioid overdose?
It renders a person drowsy or unconscious and it depresses their breathing: it can make it too slow, shallow and ineffective, it can obstruct your airway or it can stop breathing all together.
Can I ask you if you know How Naloxone works?
Naloxone blocks the effects of an opioid. Your security officers have nasal Naloxone here on campus, it is a simple squirt in the nose much like a nasal decongestant and it will block the effects of opioids. It takes time to work, after about 2 to 4 minutes a person experiencing an opioid overdose will start to wake up and will start breathing, administering CPR until the person is breathing is crucial. There is absolutely no harm if you give Naloxone to a person who did not need it. An opioid overdose requiring Naloxone is a near death experience, the Naloxone got the person breathing again and prevented the death.
Are you both trained in basic first aid/CPR… do you know what to do if someone collapses and becomes unresponsive?
***Give them the red cross CPR handout and treatment of overdose handout
The point of basic first aid/CPR is to recognize a potential cardiac arrest, quickly activate 911 and keep the person alive with CPR long enough for help to arrive.
If someone’s heart is not beating or if they are not breathing adequately, permanent brain damage will start in about 4 minutes. Death will happen a couple of minutes later. The longer you leave someone with inadequate breathing or an inadequate heartbeat, the more likely they are to die, or suffer brain damage.
In basic first aid CPR training, they realize people are lousy at detecting pulses and they realize people are not great at determining if someone is breathing… so they keep the teaching very simple.
Basic first aid/CPR training teaches what is outlined in that simple poster:
If you come upon a person who has collapsed or is unconscious, call 911, check if they are responsive, if they are not responsive check their breathing, if their breathing is not normal start CPR.
Survival is dependent on three main things: the time it takes to start CPR, the underlying cause of the collapse, and the underlying health of the victim.
A witnessed collapse from an opioid overdose in a young healthy person should be 100 percent survivable. All you have to do is breath for them until you either give Naloxone and it kicks in, or until a paramedic comes and puts a breathing tube in their throat so that a machine can breathe for them until the drugs wear off. An opioid overdose is mostly just a breathing problem.
Before getting to the night of Sidney’s death I just want to go over a bit of a backgrounder:
In 2016 British Columbia declared its first a public health emergency, this was in response to overdose deaths from the highly toxic drug supply. This public health emergency is ongoing…. there are currently 7 deaths per day in the province of British Columbia from the toxic drug supply. Opioid overdose is the leading cause of death in the average age of the population at this University.
The drug supply is increasingly poisoned with fentanyl, particularly here in in British Columbia. There is a risk of fentanyl being in all recreational drugs including those that students are most likely to experiment with.
In January 2023 BC decriminalized possession of opioids, cocaine, methamphetamine and MDMA for personal use. Whether you agree with this policy or not, students over the age of 18 can legally possess enough fentanyl to kill an entire auditorium of opioid naïve individuals.
Students who think they have pills or powders that they believe to be Ecstasy, Molly, MDMA or cocaine often contain fentanyl. Police can’t even seize these drugs anymore, even from a group of partying students who have no idea how toxic the drugs may be.
The occasional recreational drug user is at very high risk of death if exposed to fentanyl because they have no tolerance too it and very small doses will kill them.
Before going on, can we agree that it is generally accepted that the part of the brain that controls decision making is not fully developed until around the age of 24? As a result, teens and young adults are at risk of making poor decisions and are less able to consider the consequences of their choices. As educators you must know this, that it is developmentally normal for teens to sometimes make poor choices. Do we agree on that?
Just going back to a bit more background before getting to the night of Sidney’s death,
In September 2023 the current group of first year students at U Vic were oriented to dorms and campus. During the orientation to dorms, students were encouraged to call campus security for all emergencies.
**give them the poster: this is from the third-floor bulletin board at the residence where Sidney died: ‘always contact campus security first for emergencies’
We were pretty surprised by that. At our first meeting with the university after Sidney died, the director of campus security confirmed that the university does in fact encourage students to call them for all emergencies. She told us that campus security officers are trained in first aide specifically they have OFA level 2 training, they are trained to administer naloxone, they carry naloxone, and they are trained in using an AED. She also said the reason for calling campus security is that the campus is a big confusing place, and the security is best suited to make sure 911 responds to the right location to get a timely response.
The messaging to students, right since orientation, is to contact campus security for emergencies, including medical emergencies.
I also want to review what did not happen at orientation in dorms at UVic, including what is not in the community living handbook:
-There was no orientation or information about the toxic drug supply in BC, and that many recreational drugs including the ones that students are most likely to experiment with, are contaminated with fentanyl that can kill them
-There was no orientation to the risk of overdose with recreational drug use.
-There was no information about how to recognize a possible drug overdose
-There is no information about what to do in the event of an overdose
-There is no information about where to get naloxone for free on campus
-There is no information about the harm reduction center on campus
-The University does not make naloxone available in dorms
-The Community Leaders in dorms do not require basic first aid/CPR and do not have access to Naloxone in the dorm
As far as you know, did I get that right?
Moving up to January 2024
There was a least one opioid overdose on campus that campus security responded to and treated with Naloxone the weekend prior to Sydney’s death. We were initially told that there were seven, but the head of campus security then changed her story and said there was one.
From what we understand, the other campus security officers, in particular the ones on the night of Sidney’s death were NOT informed about the recent overdose on campus to make sure they would be prepared if they encountered an overdose.
January 23, the night Sidney had a cardiac arrest in one of your dorms:
For some context (pseudonyms are used):
Leah is our daughter’s friend, and she lives in the residence where my daughter collapsed. She is the second unconscious student
Gwen lives in the room next to Leah, she is not a friend of our daughters, our daughter’s cardiac arrest occurred in her room
Emma is one of the four student responder who called campus security.
So that you understand that the account and timeline that I am going to give you are accurate, I am going to list the sources we used to piece together the details of the last 15 minutes of Sidney’s life:
-We reviewed the 911 call transcript; BC ambulance gave us specific times from time stamps correlating to different parts of the call
-We communicated with 5 different students who witnessed and responded to Sidney that night, including the student who called campus security, as well as the student who met the firetruck when they arrived. We have written accounts from the 5 students.
-We have had some very brief correspondence with Gwen who called 911, and we have communicated with Leah.
-We reviewed the fire incident report and we communicated with the fire chief
-We reviewed the ambulance report
-We listened to the campus security tapes related to the response including the call from Emma to campus security… that call had time stamps so we are certain of the times.
-We reviewed the internal campus security report written by one of the responding security officers
-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 would like a copy of those.
I can tell you with certainty that the times I am going to list are accurate.
We don’t’ know exactly how Sidney was exposed to fentanyl. None of her friends have ever known her to use hard drugs, she was not known to party on week nights, there were no vape pens, no drugs or drug paraphernalia in her dorm room when we packed is up.
We know that somehow, soon after Sydney arrived at Leah’s place after finishing school for the day, Sidney ingested fentanyl along with Leah and Gwen, probably in the bathroom.
We also know that she had a witnessed collapse from a fentanyl overdose, that campus security was contacted immediately and that Sidney died. What I am going to describe are the events that occurred between the time that Sidney collapsed and the time campus security started CPR on our lifeless child, approximately 16 minutes after she collapsed.
Around 6:32 pm, a group of students who live on the 3rd floor of a University of Victoria residence heard a commotion and a loud thud in the hallway and immediately ran to investigate.
-They found Gwen dragging an unconscious student by the arm and she told the responding students that the unconscious student was just sleeping and asked if they could help drag her into the room.
– Leah was unconscious on the floor in the doorway of the room.
-Sidney was unconscious on the floor inside the room.
-The responding students immediately recognized that they were not sleeping.
-According to the students, Sidney was initially stiff for about a minute with some twitching of one of her hands, but then was still.
-Leah had gasping breathing and some jerking motions.
-the student responders realized that they were unconscious and thought that they were seizing.
-Emma, a sober responsible student responder, immediately called campus security and asks someone to call 911.
-Tragically, it wasGwen, the girl who was impaired on fentanyl, the one found dragging an unconscious kid into her room, that volunteered to call 911.
-To be very clear, the student responders did not initially realize Gwen was involved, but it quickly became obvious that she was impaired.
-Tragically, Gwen remained the only person from the campus to ever call 911… it took over 7 minutes for 911 to dispatch fire and ambulance.
-The firefighters who eventually responded to Sidney came from the firehall that is literally across the street from University of Victoria, it took them 15 minutes to get to our daughter’s side.
-While Gwen phoned 911, Emma called campus security.
-Campus security dispatch received Emma’s call at the same time as Gwen contacts 911.
-Emma tells campus security that there are two girls seizing and asks him to send someone.
-He clarifies the location and quickly dispatches two security officers to the scene.
-He offers to put Emmathrough to 911 but chooses not to when she tells him that ‘one of the friends are on 911 already’.
-He asks details about names and student numbers and then campus Security dispatch tells Emma that he will stay on the line with her until security arrives and to let him know if anything changes.
–37 seconds later, about 2 minutes and 37 seconds into the call, Emmatells campus security dispatch that the students are turning blue.
– then SILENCE
-there is absolutely no response from the security officer on the phone
-he doesn’t ask if the ambulance has been dispatched
-he does not ask if 911 has been told that the students are blue
-he does call 911 himself to make sure an ambulance is coming
-he does not inform the two security officers who are on the way to the scene so they can be prepared
–911 never receives the information that the two unconscious students were turning blue as early as 3 minutes into their call
– 60 seconds of silence goes by after Emma tells security that the girls are blue, and Emma then tells security dispatch that their eyes were rolling back.
-Once again, the response from security on the phone is silence.
-In the parallel call between Gwen and 911, when Emmais telling security the girls are blue, 911 is still trying to get the address from Gwen and has not even asked why she is calling
– approximately 4 minutes after the call, campus security officers arrive at the scene: two security officers trained in basic CPR and carrying Naloxone
-In the UVic security document, campus security describes arriving to two unconscious students in respiratory distress.
-the security audio of the call clearly established that both girls were blue before security arrived.
-Despite being unconscious and not breathing properly, security did not initiate CPR on arrival.
–They waited 12 minutes after they arrived to start CPR.
-They could have easily kept Sidney alive if they had just followed the very basics of any first aid training and initiated CPR when they arrived.
-They arrived in time to save Sidney and instead they denied her the care she needed until it was too late
So, what did the security officers actually do after they arrived to that scene?
-They adjusted Leah’s airway when she was gurgling (that is good)
-They checked for pulses, which they describe as weak,
And then they asked questions and listened to Gwen communicating with 911.
-They asked Gwen if she had taken drugs, this is a student who was impaired and having difficulty following simple commands… tragically she denied drug use
-They asked bystanders if they knew if the students had taken drugs
-One of the bystanders said Leah and Gwen had used weed earlier, but that should be out of their system.
-One student said it was possible they used drugs in the bathroom.
-They tried to get Gwen to convey to 911 the location where the ambulance should attend.
–Even though Gwen was obviously impaired and was having difficulties following simple instructions, Campus security left Gwen as the only person to speak to 911 for another 5 minutes after they arrived.
-You could certainly forgive this if they were actively performing CPR or doing anything useful to help Sidney and Leah but they weren’t.
-911 did not dispatch an ambulance for close to 7 minutes while talking to Gwen
So, let’s get back to what security did do
-Security administered Naloxone…. 9 minutes after they arrived to this scene.
9 minutes
– they were in a university dorm with two unconscious blue students who were not breathing properly, a third obviously impaired student,
AND, from their questions, the idea of a drug ingestion definitely occurred to them very early on….
-And yet they waited for the impaired student to admit to taking drugs before they gave the students who were dying, Naloxone.
-This is on a campus that had a drug overdose three days prior, in a province with an opioid overdose epidemic where thousands of people are dying each year.
-Think about that… what else could this possibly be? There are two unconscious kids who are not breathing well or maybe not even breathing at all, with a third impaired student in a university dorm.
– Why would you wait for a confession from the only student awake before giving naloxone to the kids who are dying?
– this is truly inconceivable to us, especially since you had an overdose on campus requiring Naloxone 3 days earlier.
-There is absolutely no harm if Naloxone is given to someone who did not take opioids, and it is very easy to administer.
-Both of your officers were supposed to be trained in Naloxone so would have known that, although one of them had their training over a year and a half ago so he may have forgotten….
-When there was an overdose on campus 3 days prior, the university should have made sure their responding officers remembered how and when to use Naloxone.
-Fortunately for Leah, she responded to the Naloxone and woke up within about 3 minutes
-As you know, tragically, Sidney was not fortunate enough to survive your catastrophic medical response
-Honestly, if campus security just missed the Naloxone but had at least done the vary basics in first aid when they responded to two girls who were unconscious and not breathing properly, Sidney would be alive.
simple, simple, simple… call 911 and initiate CPR
Your University tells students to call campus security for emergencies, and when campus security responded to Sidney when she was blue and unconscious they failed to provide the very, very basics in first aid. Sidney had a witnessed collapse from an opioid overdose, campus security showed up in time to save her and instead they allowed her to die.
Had emergency responders been dispatched sooner they could have saved our daughter even if your team completely failed to act. They would likely have been dispatched sooner if campus security had called 911 themselves, especially when they were notified of the deteriorating condition of the girls. The firehall is across the street from the University. It took them 15 minutes to get to our daughter’s side.
Had Emma called 911 instead of your campus security, our daughter would likely be alive as fire would have been dispatched sooner and 911 could have talked Emma through what to do when she told them that the kids were blue. Instead, your security staff kept the competent sober student on the phone with them, and then did not even respond or do anything when she told him the students were deteriorating… that they were turning blue.
Do you appreciate how easy it is to treat a witnessed collapse from an opioid overdose and that Sidney would be alive if this had happened almost anywhere else in Victoria or Vancouver? We are absolutely overwhelmed by the medical response by the University of Victoria to Leah and Sidney’s overdose.
What do you think about the response and the fact that your two medical responders waited 12 minutes to initiate CPR on Sidney when she was unconscious, blue and either barely breathing or not breathing. Seven years into the opioid public health emergency, where 7 people per day are dying of opioid poisoning, and your security officers who you advertise as ‘highly trained medical responders’, not only failed to initiate basic life support, but they waited until an impaired student admitted to taking drugs before they gave Naloxone to two dying students.
Can you tell us why the security officers weren’t informed of the overdose on campus several days earlier? An opioid overdose requiring Naloxone is a near death experience, presumably you don’t have that many near death experiences on campus, so I would think you would want to share this information with your other medical responders so they can make sure they are prepared, review their training… can you tell us why they were not informed of the other overdose that was serious enough to require Naloxone?
The day following Sidney’s overdose, on the 24th of January, you sent an email to students in UVic residents, and on the 26th, the day Sidney was declared brain dead, you sent an email out to the students across the campus.
**** give him the emails
Let me point out the good first. The part I highlighted in blue is good, kudos for providing some basic information on Naloxone and where to get it and links to harm reduction
Can you look at the first paragraph in both of those emails., the part highlighted in green:
‘we are receiving reports that the unregulated drug supply in BC is unsafe right now. ‘
-And in the second email: ‘As many of you are aware, there is a concerning trend of unsafe drugs in BC. At a press conference on Jan 24, BC Chief Coroner stated that nearly seven people a day died from toxic drugs in 2023 in BC’
-Staff at your university deliberately chose not to mention that there was a problem with overdoses right here at UVic, overdoses that resulted in serious harm. Kids have been hearing about the drug problem in the province for years, don’t you think it would have been more impactful to mention that there were overdoses and harms right here at UVic?
Why did you not mention that there were serious overdoses right here at UVic? Are you afraid of reputational harm if you mention drug overdoses at UVic?
I would like to put those emails aside for a moment and get back to them when we talk about your security officers as medical responders. I just want to cover a couple of things about harm reduction first.
You know that there is a very large population of at-risk young people right here at UVic, on campus and in your dorms, who you know make poor decisions at times.
You know that there is, to some extent, a party culture in dorms and that some students are going to make some very poor choices about trying things like ecstasy or cocaine.
We know that there is a huge risk, right here in Victoria, that those drugs may contain contaminants like fentanyl. So why does the university not do an orientation in dorms at the beginning of the year about the toxic drug supply, tell students how they can keep themselves safer, how to recognize an overdose how to respond to an overdose? Do you think you should do that at orientation?
Why has UVic chosen not to put Naloxone in easily accessible places in dorms and across the campus? Do you plan to make Naloxone widely available in dorms and places across campus?
Had UVIC done an orientation in dorms to the toxic drug supply in Victoria, and told students how to recognize an overdose and what to do in the event of an overdose and made Naloxone available in their dorms… do you think that one of the 5 competent students standing around watching helplessly may have saved Sidney and Leah with a squirt of Naloxone in the nose, even before campus security showed up? Do you think you should make Naloxone more widely available in dorms and across campus?
Are you afraid of reputational harm if you address drug use and harm prevention in an open and honest way and make Naloxone widely available across campus? Is that why you have not done this?
At minimum, why are community leaders in dorms s not trained in CPR and provided with Naloxone?
Can you go back to those emails that you sent to students at UVic after Sidney’s overdose please? You can look at the second one, the one dated January 26th, they both more or less say the same thing on the topic that I want to speak about. Can you look at the lines that I highlighted in orange:
‘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. Please program this number into your phones’.
Three nights prior to that email, campus security was called right away for a witnessed collapse. Campus security officers showed up to two blue unconscious students that were not breathing normally, and they waited 12 minutes after arriving to that scene, to initiate CPR, enough time for Sidney to suffer a catastrophic brain injury that would kill her. They waited 9 minutes to give naloxone. Your ‘highly trained medical responders’ had just denied our daughter the care she needed until it was too late and she died as a result.
Do you see a problem with what your University said in that email to students, three days after that happened? What had changed at UVic in those three days, that made it safer to call campus security for an overdose than it was the night they were called for Sidney’s overdose?
Do you think it is a problem that campus security did not call 911 themselves on January 23rd, especially after keeping Emma on the phone and she informed them that the students were blue?
I would like to tell you a few things that I have learned about campus security and its medical responses
-There is no medical oversight.
-Security does not debrief any of their medical responses, they have no way of knowing if any of their medical responses are appropriate.
-From what I can gather, they never practice emergency scenarios to make sure they maintain their skills.
-There are no protocols on campus with how to respond to an unconscious student or a student who potentially overdosed (see addendum).
-Even after the catastrophic response where Sidney died needlessly, 10 weeks after Sydney’s overdose the head of campus security believes that her security officers did what their training told them to do.
-There is no first aid course on the planet that would train your security officers to do what they did.
-The head of security has no idea what really happened that night as she refused to interview any of the student who watched what happened. At our first meeting with University officials, we told them that Emma was more than willing to speak to them, they have not spoken to her.
Even though your security officers were involved in a death, the head of campus security was not planning to debrief them to learn what went wrong … can you imagine?
We had to push her to do this. On a call with her I had to explain why a medical debrief is important and how we do them in the emergency department… 2.5 weeks after their catastrophic failure and she had not spoken to the security officers who attended to find out what went wrong. After finally speaking with them, she came away from it believing that they did what they were trained to do, and that the scene was chaotic. That scene was not chaotic. The scene was very scary because there were two students trying to die, but it was not chaotic.
They make basic first aid training very simple so you don’t have to think to act when you come upon a scary scene… your security officers failed to act in the most basic way.
Why are you running and advertising a medical response system with what you call ‘highly trained medical responders’ when:
-you have no medical oversight,
-you give no ongoing training of what to do for serious emergencies,
-you provide no debriefing or reviews after they respond to a serious medical emergency so they can have an opportunity to learn and change their practice,
-you have no protocols for how to respond to common medical emergencies including an unconscious student or an obvious overdose (please see addendum at the bottom)
-you pay them like a security guard not a first responder
And you do this is on a campus full of vulnerable youth at high risk of exposure to recreational drugs in the midst of the current opioid epidemic.
If you really believe there are good reasons why students should call campus security for a medical emergency, at minimum, campus security should be mandated to always put the caller through to 911… ALWAYS. They can stay on the phone to clarify the address to 911 and ensure 911 will respond, and they can dispatch a security officer, but they must always contact 911.
Doing anything less, will result in delaying a 911 response, and if your security officers fail, at least 911 may get there on time.
Your school told Emma to call campus security in an emergency. Once she made that call, you had a duty to care for Sidney and your university let her die instead of providing her with the basic care that she needed. Do you believe that your school had a duty of care to Sidney after she overdosed and that your school’s failures resulted in her death?
I fully acknowledge that Sidney’s death was the result of fentanyl, and the ultimate blame rests with the people who produce and supply it.
But Sidney’s death, after an overdose here on your campus, was a result of UVic’s systemic failures. Based on the systems that you have put in place, added to the fact that you do so little in terms of harm reduction for vulnerable students in a province in the midst of an opioid crisis, the death of a student from a fentanyl overdose on your campus, …. a PREVENTABLE death after a witnessed collapse from an opioid overdose, was PREDICTABLE.
It is unconscionable, that in the midst of an opioid crisis in this province, your University chose not to speak to their students about drugs and drug use and how to minimize the risk that it poses
It is unconscionable that your University does absolutely no orientation in dorms to the risks of the toxic drug supply, and how to protect themselves and each other. This is a group of teenagers that you know are at particularly high risk. You know that there are drugs and alcohol in dorms. You know that teens are going to experiment with them. You know that teens, based on their underdeveloped prefrontal cortex, sometimes make poor choices and don’t appreciate the risk of their choices…. You as educators absolutely know this.
And yet during orientation, you still chose not to give them the information that they needed to stay safe
It is unconscionable that you have chosen not to supply naloxone in dorms and make it easily accessible across your campus to save the vulnerable youth in your care. There is no naloxone available ANYWHERE IN YOUR DORMS
It is unconscionable that you choose not to inform your students and staff about serious overdoses that occur right here at UVic. Instead you said things like ‘We are receiving reports that the unregulated drug supply in B.C. is unsafe right now’
It is unconscionable that you tell your students that you have highly trained medical responders that they should call for medical emergencies… and yet you have done nothing to prepare those responders for medical emergencies, -in particular you have no protocol for how they should respond to an unconscious student, particularly one that is not breathing well and you have no protocol on how to respond to an opioid overdose (see addendum).
It is unconscionable that you run a ‘parallel medical system’ and delay a 911 response, when your system has no ongoing training, no medical oversight, no case debriefs, no way of knowing if it is causing harms, and no basic protocols for how to respond to serious medical presentations.
Fentanyl may have killed Sidney, but your University’s response let her die.
*****Give them the handout on overdose protocol from CMHA, talks about need for Naloxone to be widely available on campus.(see addendum)
You should look at this, it is a little out of date but better than what you do. It is too late to save Sidney but you need to make some big changes at UVic to stop this from happening to another student right here on your campus.
Addendum (not talked about at the meeting):
The campus has a naloxone sheet last revised in 2017 in their Standard Operating Procedures manual that describes Naloxone, how it works, where it is stored, that it must be carried, how to use it, who to use it on and how to store it.
This is not a protocol for responding to an unconscious student or a student suspected of an opioid overdose, nor, from what I have been told, something that is reviewed regularly by security officers.
Excerpt from follow up email we sent to the president of the university:
I also implore you to read the CMHA opioid response guideline that I supplied yesterday and have attached again here. Both you, and the head of campus security, have told us that you do not make Naloxone available in dorms and instead keep it with campus security. The excuse that you gave for this, is that you believe Naloxone will be tampered with in dorms. This is not an acceptable reason. As I mentioned in our meeting, smoke alarms and fire alarms are tampered with in dorms…. the solution was not to remove them and instead have security come to the building and yell ‘fire! fire! fire!’ if a student smells smoke or sees fire. That would be dangerous. It was equally dangerous for our daughter that you did not supply Naloxone in dorms and relied on security to show up with it and administer it.
I wonder if you can share the information in the following link with your senior leaders when considering what to do to make your campus safer. These boxes combined with a decent orientation would go a long way to protecting kids, especially if campus security cannot arrive quickly, or does not act when they arrive, or if there is a delay to fire/paramedic arriving.
University of Victoria’s Office of the President denies that they prioritize protecting their reputation above protecting the safety and well-being of their students.
UVic Admin:
If after reading this website you would like to contact the University of Victoria administrators, here is their contact information:
“Naloxone on the shelf of a nurse’s office or in the cupboard of a health center is not the optimal place to store the drug simply because the window to respond to and reverse an overdose is so short — literally minutes. It is imperative that naloxone be placed directly with the people who are most at risk of an overdose or are most likely to witness an overdose: the roommates, family members, friends and even relative strangers.“
The Washington Post, July 7, 2017
