Isabelle Bridie Sapherson-Moralee

Dear Mr Allen, Re: Regulation 28 Report to Prevent Future Deaths – Isabelle Bridie Sapherson- Moralee who died on 26th April 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18th June 2026 concerning the death of Isabelle Bridie Sapherson-Moralee on 26th April
2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Isabelle’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Isabelle’s care have been listened to and reflected upon. Your Report raises the following concerns:
1. There is no national treatment pathway for patients suffering ketamine addiction and ketamine associated harms despite the evidence that ketamine use and ketamine-related harms have increased.
2. 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.
3. A lack of research into the addictiveness of ketamine and 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.
1. No national treatment pathway for ketamine addiction or ketamine related harms While it is agreed that there is not a national mandated treatment pathway or specific prescribing guidelines in place, the NHS England Getting it Right First Time (GIRFT) Team are aware of the following guidance and research in place for review and use by patients and clinicians in England:
1. Advisory council on the misuse of drugs (2026) Ketamine – an updated review of use and harms, P31.

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MD_Ketamine_Review_2026-Report_.pdf
2. The British Association of Urological Surgeons (2025) Ketamine bladder – What you need to know.

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3. The British Association of Urological Surgeons (2026) Ketamine – information for patients.

4. Belal et al (2024) BJU Int. British Association of Urological Surgeons consensus statements on the management of ketamine uropathy.

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5. Beerten, Mathei and Artgeerts (2023) BJGP. Ketamine misuse: an update for primary care. https://bjgp.org/content/73/727/87 Ketamine use has increased, across both paediatric and adult populations, but patients presenting in emergency departments and other settings, with complications of recreational drug use are either rarely aware or rarely disclose the chemical providence of the drugs in their system and so it is not always clear whether people have been using ketamine or not. We also know that patients experiencing addiction have often been historically excluded from traditional holistic person-centered care approaches and find the care they need harder to access, which make this more challenging but no less important. In order to address these challenges, the Department of Health and Social Care (DHSC) and NHS England jointly published the Co-occurring Mental Health and Substance Use Delivery framework in December 2025:

substance-use-delivery-framework. The delivery framework includes recommended actions on how the health system can work together to improve coordinated care, as well as actions we will take nationally to better support this. These recommended actions include an ask for services and clinicians to work as multidisciplinary teams to ensure collaborative case management and establishing joint working protocols between drug and alcohol services and mental health services. The government Advisory Council on the Misuse of Drugs also issued Updated Review of Ketamine Use and Harms in January 2026: (https://www.gov.uk/government/publications/ketamine-an-updated-review-of-use- and-harms). This also acknowledges the need for greater collaboration between community drug and alcohol treatment services, primary care, social care, mental

[Page 3] health services, hospitals and relevant medical specialties to provide holistic support for people experiencing ketamine-related harms. NHS partners are working with the department to strengthen awareness, referral pathways and coordination of care for people with ketamine use disorder and its associated complications in line with this review. National clinical pathways are therefore not planned for each individual drug, but local services are commissioned to support the most prevalent drugs in local use, as well as generic pathways, and this is now common practice for ketamine use in line with the resources above. NHS England will communicate with Regional Medical Directors, Chief Medical Officers and Chief Nursing Officers to support the dissemination of information on the public health impact of illicit ketamine use and associated harms. This will include information to assist healthcare professionals in recognising ketamine-related complications, referring patients to appropriate services and delivering integrated packages of care.
2. Prescribing guidelines for ketamine bladder syndrome in primary care There aren’t currently any prescribing guidelines for ketamine bladder syndrome in primary care. The British Journal of General Practice produced the following update for primary care. However, in light of this case, the lack of guidance will be reviewed in relation to pain management in patients using non-prescribed ketamine and/or experiencing ketamine use disorder, and in line with the holistic guidance above.
3. A lack of research into the addictiveness of ketamine and ketamine-related harms means and no national processes to develop effective care plans The Mental Health Personalised Care Framework concentrates on the approach and related actions services should take to deliver personalised care for people with severe mental health problems. Services should consider how these actions will be enabled including embedding guidance on management of co-occurring conditions and joint working protocols with drug and alcohol services. We are aware your report has also been addressed to the DHSC who will provide more detail but we understand that DHSC are continuing to invest in improvements to local drug and alcohol treatment services, and are supporting local areas to provide additional non-opiate treatment places through the Public Health Grant and supplementary substance misuse grants. Nationally, the Young People’s Substance Misuse Treatment Statistics 2023 to 2024 report published on 28 November 2024 by Office for Health Improvement and Disparities (OHID) showed there was a rise in the number reporting problems with ketamine, from 512 (4.5%) in 2021 to 2022 to 1,201 (8.4%) in 2023 to 2024, which

[Page 4] means more children and young people reported problems with ketamine than with cocaine for the first time. Statutory guidance on relationships, sex and health education (RSHE) requires all primary and secondary schools to ensure that pupils know the key facts and risks associated with drug and alcohol use, as well as how to manage influences and pressure, and keep themselves healthy and safe. The department has worked with the Personal, Social, Health and Economic Education Association to develop the lesson plans on drugs and alcohol and has commissioned an update to the resources to be published later this year. OHID also offers easy to read information on the risks of using ketamine and some basic harm reduction advice on its drug information site, FRANK. Regional Response Dorset Integrated Care Board (ICB) have advised South West Regional colleagues that the commissioning of addiction support services primarily sits with the local authority and public health teams. Dorset ICB have advised that ketamine has been a subject of interest in the combatting drugs partnership with dedicated campaigns to inform people of the risks and dangers associated with use. Drug & Alcohol commissioners within the local authority and public health teams are currently working on a local care pathway for people presenting with ketamine related issues. Dorset Council Public Health Colleagues have advised us of another Prevention of Future Deaths Report where concerns were focused around the risks associated with ketamine remaining a Class B drug. Both drugs were reviewed through the Pan-Dorset drug related death review process. We were advised that the Dorset Council Public Health team have completed a deep dive into the increasing numbers of young people presenting for treatment with ketamine as their primary drug which has led to a programme of work to try and address the increasing number of young people presenting for treatment with ketamine as their primary drug. Subsequently, the public health team at Dorset Council led the following response:
1. A Pan-Dorset webinar focused on educating front line professionals across the health and social care systems on the risks of ketamine and support available through drug and alcohol treatment services in June 2025.
2. A Pan-Dorset comms campaign focused on risks of ketamine and how to get support aimed at 18-25 year olds which was funded by two Local Authorities and Police and Crime Commissioner ran between December 2025 and March
2026.
3. A new local care pathway for ketamine bladder developed in West Dorset involving Dorset County Hospital urology services, Reach and the community pain service. Bournemouth, Christchurch and Poole (BCP) Council are leading a similar piece of work for East Dorset linking to services in University Hospitals Dorset.
4. Pan-Dorset primary care guidance developed (involving Reach and local NHS professionals from primary care and pain service) which made

[Page 5] recommendations for prescribing for pain associated with ketamine use and outlined the importance of timely referral to urology and drug and alcohol treatment services.
5. Communication sent to Dorset pharmacies through Community Pharmacy Dorset highlighting the symptoms of ketamine bladder which can mimic a urinary tract infection and the need for GP review where an individual is using ketamine. BCP Council Drugs and Alcohol Adults & Young People Adult Social Care Commissioning Strategic Commissioning Manager has advised that some impatient detoxification units are now accepting ketamine users however this is having to be person centred treatment and therefore is expensive and taking up a lot of occupancy in a valuable resource at a considerable cost as inpatient units are funded separately on a per night basis. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Isabelle, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Allen, Thank you for the Regulation 28 report of 18 June 2026 sent to the Secretary of State for Health and Social Care about the death of Isabelle Sapherson-Moralee. I am replying as the Minister with responsibility for Public Health. I was saddened to read of the circumstances of Isabelle Sapherson-Moralee’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report. Your report raises concerns over the coordination of care for patients experiencing ketamine related harms, guidance to support safe prescribing where ketamine use is a concern and the need for research and understanding of ketamine dependence and associated harms. The Government's response to each concern is set out below.
1. Coordination of care for patients experiencing ketamine-related harms This Government recognises the increasing prevalence of ketamine use and the growing number of people experiencing ketamine-related harms, including severe urological complications and dependence. We know that people with co-occurring substance use and other health needs too often do not receive the integrated, person-centred care they require and deserve. I want to assure you that the Department of Health and Social Care (DHSC) is taking action on this important issue to improve the standards of care and integration of services for those with co-occurring substance use and other health needs. In December 2025, DHSC and NHS England (NHSE) jointly published the Co-occurring Mental Health and Substance Use Delivery framework: https://www.gov.uk/government/publications/co- occurring-mental-health-and-substance-use-delivery-framework. The delivery framework includes recommended actions on how the health system can work together to improve coordinated care, as well as actions we will take nationally to better support

[Page 2] this. These recommended actions include an ask for services and clinicians to work as multidisciplinary teams to ensure collaborative case management and establishing joint working protocols between drug and alcohol services and mental health services. DHSC is now looking at how to better co-ordinate physical health pathways with drug and alcohol treatment services drawing on the experience of the Co-occurring Mental Health and Substance Use Delivery framework. You also highlighted the recommendation for greater collaboration made by the Government’s Advisory Council on the Misuse of Drugs (ACMD) in their Updated Review of Ketamine Use and Harms, January 2026 (https://www.gov.uk/government/publications/ketamine-an-updated-review- of-use-and-harms). DHSC recognises the need for greater collaboration between community drug and alcohol treatment services, primary care, social care, mental health services, hospitals and relevant medical specialties to provide holistic support for people experiencing ketamine-related harms. We have started work in response to the review and this recommendation. As part of this, the Department is working with NHS partners to strengthen awareness, referral pathways and coordination of care for people with ketamine use disorder and its associated complications. NHS England will communicate with Regional Medical Directors, Chief Medical Officers and Chief Nursing Officers to support the dissemination of information on the public health impact of illicit ketamine use and associated harms. This will include information to assist healthcare professionals in recognising ketamine-related complications, referring patients to appropriate services and delivering integrated packages of care. In 2024, DHSC published a toolkit for drug treatment services and other stakeholders which provides information on ketamine-related harms, prevention, treatment and healthcare system responses, including the importance of referral pathways and joint working to support integrated care. DHSC will review and update this resource, to be published in the autumn, to ensure that it remains aligned with NHS England communications, emerging evidence and developing good practice. In 2025, DHSC also launched a communications campaign raising public awareness, which included a ketamine factsheet for local authority public health teams to cascade to health partners. The factsheet provided information on the risks associated with ketamine use and supports frontline professionals to identify problems early, make appropriate referral and provide integrated treatment. DHSC is also supporting work led by the British Association of Urological Surgeons (BAUS) to improve awareness of ketamine-associated bladder damage among urologists and strengthen referral and treatment pathways between specialist healthcare services and drug treatment providers. Because patterns of illicit drug use change and evolve over time, national clinical pathways are not developed for each illicit drug but general principes, which apply to ketamine use, are outlined Drug Misuse and Dependence: UK Guidelines on Clinical Management (commonly known as the "Orange Book", https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk- guidelines-on-clinical-management). However local drug and alcohol treatment services develop specific pathways for prevalent drugs, as well as generic pathways, and this is now common practice for ketamine use. Many of the larger national and regional providers and some national membership bodies have developed ketamine resources, pathways and practice sharing events

[Page 3] and networks. We are confident the system is responding and the Government is taking forward a range of actions designed to improve coordination between services to support the delivery of holistic multidisciplinary care, in line with the ACMD's recommendations.
2. Guidance to support safe prescribing where ketamine use is a concern The Government recognises the importance of safe prescribing for all patients. Decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care. Prescribers are accountable for their prescribing decisions. Prescribers must always satisfy themselves that the medicines they consider appropriate for their patients can be safely prescribed and that they take account of appropriate national guidance. The Clinical Guidelines on Drug Misuse and Dependence is the nationally recognised clinical guidance for clinicians on the treatment of substance misuse and dependence. The guidance includes advice on prescribing practice, risk assessment, management of comorbidity, shared care arrangements and communication between specialist and primary care services. In particular, Chapter 4, Pharmacological Interventions, and section 4.2, Prescribing, set out principles of safe prescribing in the context of substance misuse treatment. Prescribers are expected to consider the risks and benefits of treatment and to utilise established medicines information resources, including the British National Formulary (BNF), which provides information on indications, cautions, contraindications and clinically significant drug interactions. These resources support informed prescribing decisions across all care settings. The ACMD’s review also recommended the development of clinical guidance for the off-label use of ketamine or esketamine. The responsibility for the development of detailed clinical prescribing guidance rests with healthcare providers, professional bodies, Royal Colleges and system regulators. Providers are expected to maintain appropriate local governance arrangements, clinical protocols and standard operating procedures to ensure the safe use of controlled drugs, including where medicines are prescribed outside their licensed indications. Where concerns arise regarding the prescribing of medicines with dependency-forming potential in individuals with current or previous substance misuse problems, local authorities commission specialist drug and alcohol treatment services staffed by appropriately trained clinicians. These services provide assessment, treatment and specialist advice to support GPs and other healthcare professionals in the management of complex cases. The Orange Book emphasises the importance of collaborative working and shared care between specialist treatment services and primary care in order to support safe and effective clinical management. The Department is also working to ensure information can be shared more easily between local authority commissioned drug and alcohol treatment services and NHS services. The Department therefore considers that the current framework provides:
- nationally recognised clinical guidance through the Orange Book;
- access to prescribing and drug interaction information through the BNF and other established medicines information resources; and

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- access to specialist addiction services that can support prescribers in the management of patients with complex substance misuse histories.
3. Research and understanding of ketamine dependence and associated harms The Government acknowledges that further research is required to improve understanding of the long-term consequences of chronic ketamine use and to inform future prevention and treatment responses. However, an increasing body of evidence has developed in recent years regarding the harms associated with chronic ketamine use. These include dependency, significant urinary tract and bladder damage, gastrointestinal complications, mental health harms and impacts on quality of life. Much of this evidence was considered by the ACMD in its recent updated review of ketamine use and harms. To strengthen the evidence base further, DHSC has commissioned research examining patterns of ketamine use and the characteristics of people who use ketamine. The study is expected to conclude in 2027 and gather qualitative data from people who currently use ketamine, people experiencing ketamine-related harms and individuals both receiving and not receiving treatment. The research will improve understanding of the motivations for ketamine use, determinants of dependence, barriers to accessing treatment, routes to recovery and unmet treatment needs. The findings will help inform future policy and service development. Alongside this research, DHSC continues to monitor trends in drug use, treatment demand and health harms. Information on treatment presentations is routinely collected through the National Drug Treatment Monitoring System (NDTMS). DHSC is also working with NHS England analysts to explore the use of additional data sources to improve understanding of trends in ketamine-related hospital admissions and associated health conditions, including ketamine-associated uropathy. This aligns with the ACMD’s review recommendation 14 that ketamine use and related conditions should be included in health service data collection to facilitate monitoring and enhanced system responses. The Government is working with NHS partners, researchers and clinical experts to improve the evidence base regarding ketamine-related harms and to ensure that services are informed by the best available evidence. I am grateful to you for bringing these important matters to my attention. The Government remains committed to reducing drug-related harms, improving access to effective treatment and ensuring that healthcare professionals are supported by appropriate evidence, guidance and specialist services. We will continue to work with partners across the health and care system to improve outcomes for people affected by ketamine use and its associated harms.