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University of Victoria student Sidney McIntyre-Starko, who died after taking a tainted drug. VIA FAMILY

An American doctor who created the computer software used by ambulance dispatchers in B.C. was peppered with questions about how to improve the widely used system, during a coroner’s inquest on Monday.

The five-person jury, in its third week of hearing evidence about the 2024 fentanyl-poisoning death of a University of Victoria student, made several suggestions for change to Dr. Jeff Clawson. He is the founder of the Priority Dispatch system, which is used in most ambulance 911 calls in Canada, including all in B.C.

Why, one juror asked, didn’t the call-taker follow up on her suspicions and just directly ask the student who phoned 911 if the two unconscious patients had taken drugs, rather than follow the system’s rigid rules about not asking leading questions?

“We’re definitely looking at it. It makes sense if it can be done right,” Clawson said.

Sidney McIntyre-Starko, 18, and a friend collapsed in a UVic dorm, but the student who phoned 911 didn’t reveal the three of them had taken drugs. She described her friends as turning blue and “seizing,” which led the call-taker into the seizure protocol on her computer system, delaying the urgent life-saving response required to reverse an overdose.

The inquest has heard the call-taker suspected the students could have overdosed, but was prohibited by the Priority Dispatch system from asking that specific question.

Instead, Clawson testified, the call-taker asked several clarifying questions to try to get to the root of what happened.

But the juror noted they all sounded the same — What happened before this? Was anyone else with them? What’s going on now? — and didn’t result in new information being provided in an urgent way.

“Instead of asking all of those multiple times, one of those (questions) could have been: ‘Were there drugs involved?’ ” the juror put to Clawson.

When the seizure protocol was chosen for this case, a box popped up warning the call-taker it was an unusual medical complaint for two patients. That required her to confirm she wasn’t mistaken about this choice.

Wouldn’t that be a good place to ask the call-taker to make more follow-up questions? a juror asked.

Clawson said that change is under discussion, but said none of the 3,000 centres worldwide that pay to use his software has submitted this exact proposal for change.

“Maybe you can be the one that does,” Clawson told the juror. “That (proposal) does make some sense, and that’s actually on my list of things here that we want to look at based on learning from every event as much as possible.”

Call-takers are typically not medically trained. They rely on the Priority Dispatch system to guide them through 911 calls by entering information provided by witnesses and then getting next-step questions and medical advice from the algorithm.

A juror asked Clawson what potential changes could be made to the system in light of McIntyre-Starko’s preventable death.

He said possible changes that have been mentioned include improving the breathing tool that call-takers rely on to get witnesses to test whether a patient is breathing.

The inquest has heard that witnesses are unable to complete this test in nearly a third of cases. In McIntyre-Starko’s case, it took three people — including two security guards with first aid training — before it was completed, a full five minutes after the call-taker first asked for someone to do it.

Other areas Clawson said could be changed include how to better identify when someone is having a seizure, and how to better handle calls with more than one patient. In McIntyre-Starko’s case, it was never clear on the 911 call which patient the witnesses were talking about when they reported medical information, so the call-taker did not realize that one student was still “seizing” while McIntyre-Starko was largely lying motionless.

The seizure protocol guided the call-taker to ask a series of questions that seemed bizarre when there were two patients: Are they both pregnant or do they both have brain tumours?

One juror asked if the software could be changed so that in a multiple patient situation, the questions would make more sense, such as probing about a poisoning, noxious gas or overdose.

One of the students survived but McIntyre-Starko died of oxygen deprivation. She did not receive naloxone for 13 minutes or CPR for 15 minutes after her friends phoned 911.

Anthony Vecchio, the lawyer for McIntyre-Starko’s family, took Clawson through a report on her death written by an arm’s length company that approves changes to the Priority Dispatch software.

The report recommended some internal improvements, which included “loosening” dispatch requirements for a confirmed overdose to just a suspected one, to speed up getting treatment to patients.

Clawson said that recommendation will be reviewed, but noted it “is not an easy one to do.” He also argued McIntyre-Starko’s 911 call-taker “went above and beyond the call of duty” trying to find out whether the students took drugs.

Since naloxone is benign and cannot hurt anyone, Vecchio asked, why not just allow call-takers who suspect an overdose to advise bystanders to administer it right away.

Clawson responded that not all call-takers will have overdose suspicions, so they are reliant on witnesses to tell them what happened. “I wish we were clairvoyant and we could do that,” he said.

McIntyre-Starko’s call-taker spent 3½ minutes in a provincial database trying to find an address for the 58-year-old UVic dorm, before going to the Priority Dispatch system to start asking the witness why she was calling.

Clawson said his system could not provide a prompt for call-takers to move with more urgency after address delays, because there is no way for it to know how long has been spent in the B.C. database — or in the hundreds of separate databases used by its other clients.

“I’ll be dead and buried by the time that happens. That’s just not going to happen in the real world,” he said. “If I could be magical, I would make it happen.“