Isabelle Bridie Sapherson-Moralee

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 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:  
i.          There  is  no  national  treatment  pathway  for  patients  suffering ketamine  addiction  and  ketamine  associated  harms  that  co-ordinates 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.