“During the inquest evidence was heard that: i”

The coroner’s concerns

1. During the inquest evidence was heard that: i. Although there was engagement between local drug treatment services and Isabelle’s GP, the evidence was this is rare, despite it being recognised that a multi-agency approach to ketamine addiction, given its significant negative health outcomes, is effective in co-ordinating services and the care of patients suffering with ketamine addiction. In the year prior to her death, Isabelle was referred to the Pain Management Team, was under the care of gastroenterologists during a hospital admission and was referred to the Eating Disorders Team and the Community Mental Health Team and was a service user of the local drug treatment service. There was no co-ordinated review of the care Isabelle required that involved all of the agencies/specialisms to 2 which she had been referred. Evidence was heard that there are no national policies and processes that address ketamine addiction and ketamine-related health conditions, with no recognised pathway that brings together the specialisms required to treat patients suffering ketamine addiction and ketamine-associated harms. A lack of a co-ordinated approach to care risks patients “falling through the cracks”, with their addiction and associated medical conditions not being adequately addressed, and a consequent risk of death from the consequences of ketamine use. ii. Isabelle was prescribed morphine for pain relief. There were difficulties in her prescribing due to concerns relating to concurrent ketamine use and the potential interactions of the drugs. I heard there are no guidelines available to those in primary care to assist with safe prescribing where ketamine use remains a concern. Safe prescribing guidelines can also assist patients in understanding the potential harms associated with the combination of prescribed medications and illicit ketamine, potentially reducing the risk of unintended overdose. iii. There is limited research on the addictiveness of ketamine and the consequences of chronic ketamine use. It is noted that this aligns with the findings of the Advisory Council for the Misuse of Drugs (ACMD) in their report of 28th January 2026, which recommends that “ketamine should be included in the data collected by medical services about drug use, including ambulance services, emergency departments and hospital admission statistics”. Such research and data collection will likely identify the prevalence of ketamine use and associated harms, informing the need for resources to be made available to address the risks and the harms associated with ketamine use. 2. I have concerns with regard to the following: 3 i. There is no national treatment pathway for patients suffering ketamine addiction and ketamine associated harms that coordinates the specialisms that are required, despite the evidence that ketamine use has increased and that ketamine-related harms are being seen more frequently (though, as noted below, the full extent of this is unclear). ii. There are no prescribing guidelines to assist those in primary care who are prescribing analgesia for patients suffering ketamine bladder syndrome where there are concerns about concurrent ketamine use. The absence of guidelines presents a challenging scenario for both prescribers and patients. iii. A lack of research into the addictiveness of ketamine and the collating of the data relating to ketamine-related harms means there is currently no detailed understanding of the consequences of chronic ketamine use, no national processes to assist in developing effective care plans to break the cycle of addiction and no clear understanding of the scale of the health consequences ketamine use presents.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0339

Added to Minute Book

7 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0