A coroner's inquest into the 2024 death of an 18-year-old student at the University of Victoria has ended with the jury making 10 recommendations to prevent similar deaths in the future.

The inquest into the overdose death of Sidney McIntyre-Starko's wrapped up on Thursday, May 15, at the Burnaby Coroners Court after two weeks of hearing testimony from witnesses to the death, first responders, school representatives and government workers.

On January 23, 2024, McIntyre-Starko and another student collapsed onto their dorm floor after they were exposed to fentanyl. A third student who was also impaired managed to call 911 and tell an operator they needed emergency help. It took more than seven minutes to dispatch paramedics, according to records shared by UVic.

Her loved ones called for the coroner's inquest, saying McIntyre-Starko's death may have been prevented had she received naloxone and CPR in a more timely manner.

The juryÎÚÑ»´«Ã½™s first recommendation was directed to Education and Child Care Minister Lisa Beare, urging her to advise school districts to teach students CPR and how to use AEDs, provide training on administering nasal naloxone, and deliver presentations on drug identification and the risks of substance use.

The second recommendation, to Beare and the Minister of Post Secondary Education and Future Skills, Anne Kang, was that both ministries create a program involving in-person, informative presentations about the drug crisis using real stories from survivors or family members of loved ones lost, available to all post-secondary and high schools.

UVic was recommended to create a mandatory orientation that includes how to contact 911 and campus security, information on naloxone and using AEDs, information on safe drug testing and the drug crisis, and a one- to two-page course summary for future reference. It was asked to implement the course within campus security training.

Kang and BC Emergency Health Services (BCEHS) were recommended to consult with post-secondary schools and municipalities to install unique addresses in multi-building complexes and to include those addresses in official maps, require schools to update maps annually and to install a building map on the back of each campus residentÎÚÑ»´«Ã½™s door.

Kang's ministry was also advised that campus security at post-secondary institutions should be provided with additional equipment, including supplemental oxygen, naloxone, AEDs, OFA2 (occupational first aid) training, and oxygen and pulse finger monitors.

Campus security should be allotted work time each semester to review training materials, protocols, and best practices. The jury also recommended installing cameras in public areas. In the event of a serious incident, security should conduct post-incident debriefings. Additionally, if naloxone is administered on campus and the individual does not go to hospital, security should follow up with the person 30 minutes later, and twice more at 30-minute intervals.

Because the paramedic did not have McIntyre-Starko's name when she was admitted to the hospital, the BCEHS was asked to review policy on obtaining patient identification. It was also recommended to update the computer-aided dispatch (CAD) system and upgrade its website so that data can be publicly available. They were also recommended to incorporate an internal timer to monitor how long call-takers take to obtain locations of incidents, which could alert supervisors if the process is too slow.

The inquest jury recommended that the International Academy of Emergency Dispatch review the Medical Priority Dispatch System ÎÚÑ»´«Ã½“ used by emergency dispatchers to assess call urgency ÎÚÑ»´«Ã½“ to ensure that when multiple unconscious patients are reported, it triggers an immediate delta-level response and prompts a follow-up question about potential drug involvement.

McIntyre-Starko was a first-year general sciences student who loved to play board games with family, read fantasy books, and craft and build furniture, according to a website set up by her family.