Recurring concern

Inadequate controls for hallucinogen-related psychosis risks

First to latest report 18 Dec 2020 — 21 Jun 2022

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
6

What this concern includes

Includes failures of controls specifically dedicated to preventing, recognising, assessing or responding to psychosis risks associated with hallucinogenic substances, including consideration of recipients' mental-health status before dispensing, recognition of hallucinogen exposure by mental-health professionals, and related clinical guidance, training, warnings or escalation.

What is not included
  • Excludes generic mental-health awareness, training or treatment deficiencies where hallucinogen-related psychosis risk is not identified.
  • Excludes general drug regulation, substance misuse or poisoning concerns that do not specifically involve hallucinogen-related psychosis risk.
  • Excludes psychosis unrelated to hallucinogenic substances.
  • Excludes generic dispensing, prescribing or medication-safety failures where the hallucinogen-related psychosis risk is not the deficient control.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire (Western)

    AI-generated summary

    Kate Angharad HYATT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kate Angharad HYATT was pronounced dead at Widdop Road, Hebden Bridge, on 31 October 2021; the inquest concluded that her death was suicide. The principal concern was that hallucinogenic substances were allegedly being dispensed by the Hands of Light Academy to attendees, including potentially mentally unwell people, without proper consideration of their effects, particularly on people experiencing psychosis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of consideration of the impact of hallucinogenic substances on mentally unwell course attendees

    Wider context from the report

    “The evidence at the inquest was that Kate had become depressed for the last 12-18 months of her life. Her family described her as displaying signs of psychosis. Obviously, the causes of the decline in her mental health toward the end of her life were likely complex and multiple. The evidence was however, that she had become particularly disturbed over the 3-4 months immediately prior to her death. Specifically, these symptoms had worsened significantly subsequent to her attendance at a Hands of Light Academy course in Worcestershire; which took place on 18th-22nd June 2021. ████████, ████████. My concern is that hallucinogenic substances are being dispensed by the Hands of Light Academy to attendees on its courses, potentially and/or actually mentally unwell people, without proper, or any, consideration of the impact that they may have on them. In particular is the effect of hallucinogens on psychosis sufferers. ”

    Source location

    Kate Angharad HYATT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure continued thorough screening of all prospective students before course enrolment.

    Verbatim wording from the response

    “We undertake screening of all our students prior to them undertaking any course with us. If any student divulged such a history, we would not accept them onto a course as the nature of the work is challenging and can bring up emotional content.”

    Source location

    Response from Hands of Light Academy
    Page 1 · response
    Published 22 September 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Educate staff about hallucinogen use and its potential dangers.

    Verbatim wording from the response

    “2. Educate our staff about the use of hallucinogens and their potential dangers.”

    Source location

    Response from Hands of Light Academy
    Page 1 · response
    Published 22 September 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Records show no student by that name attended, and no Academy courses were running on the dates mentioned.

    Verbatim wording from the response

    “An initial review of our records does not show any student by the above name as having attended one of our courses. On the said dates you mention, there were no Hands of Light Academy courses running.”

    Source location

    Response from Hands of Light Academy
    Page 1 · response
    Published 22 September 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Academy does not dispense the substance concerned to students.

    Verbatim wording from the response

    “Regarding ████████, Hands of Light Academy is a teaching establishment and we do not dispense the above-named substance to our students.”

    Source location

    Response from Hands of Light Academy
    Page 1 · response
    Published 22 September 2022

    Open published response

  2. East Sussex

    AI-generated summary

    Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jennifer Sarah Myfanwy Spencer's mental health deteriorated after she ingested Shamanic hallucinogenic drugs and practised Kundalini Yoga, before she deliberately fell from Beachy Head on 16 November 2019 intending to end her life. The report identifies a lack of awareness among mental health professionals about Shamanic hallucinogens and their potential to cause or exacerbate psychosis, resulting in sub-optimal assessment, treatment and care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of Mental Health Professionals’ awareness of “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis

    Wider context from the report

    “There is a lack of awareness amongst Mental Health Professionals about “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis. This results in sub-optimal assessment, treatment and care. Ayahuasca, DMT and similar “Shamanic” hallucinogens are becoming more commonplace in the UK. Greater learning about them is required by Mental Health Professionals. Ref – Therapeutic Advances in Psychopharmacology 2017, Vol. 7(4) 141-157, dos Santos, Hallak, Mouso. ”

    Source location

    Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver a national suicide-reduction support programme helping local partnerships improve safety planning, substance-misuse assessment and joint working with substance-misuse services.

    Verbatim wording from the response

    “package with the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and National Collaborating Centre for Mental Health (NCCMH) working together to support STPs in their quality improvement plans, as part of the national suicide prevention programme.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 January 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Raise awareness of shamanic hallucinogenic drugs and escalate related concerns through relevant forums.

    Verbatim wording from the response

    “Key components of this support programme include supporting services with safety planning, using resources such as The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental health services and primary care’, which includes guidance for mental health services to work jointly with local substance misuse services and having specific training in place for staff on substance misuse assessment. I know that the South East region suicide prevention lead is working to raise awareness and escalate concerns regarding ‘shamanic hallucinogenic drugs’ via relevant forums to increase awareness and understanding of this risk factor.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 January 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Invest in psychological therapies for people with severe mental illness through the community mental-health transformation programme.

    Verbatim wording from the response

    “In addition to this, as part of the NHS Long Term Plan’s commitment to transform community mental health services, we are investing £181M in psychological therapies for severe mental illness (SMI). This includes the roll-out of ‘understanding psychosis and bipolar disorder’ training, which will be rolled out across staff working in community mental health teams over the next three years. The aim of this training is to ensure those working with people presenting with psychosis recognise the diverse bio-psychosocial factors (including substance use) that can impact upon a person's mental health.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 January 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Roll out understanding-psychosis-and-bipolar-disorder training to staff working in community mental-health teams.

    Verbatim wording from the response

    “In addition to this, as part of the NHS Long Term Plan’s commitment to transform community mental health services, we are investing £181M in psychological therapies for severe mental illness (SMI). This includes the roll-out of ‘understanding psychosis and bipolar disorder’ training, which will be rolled out across staff working in community mental health teams over the next three years. The aim of this training is to ensure those working with people presenting with psychosis recognise the diverse bio-psychosocial factors (including substance use) that can impact upon a person's mental health.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 January 2021

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Public Health England is better placed to consider shamanic hallucinogens in its illicit drugs and medicines guidance.

    Verbatim wording from the response

    “Your concerns around the lack of awareness of Shamanic hallucinogens are noted. It would be relevant that colleagues at Public Health England are better placed to consider this in their work on “Misuse of illicit drugs and medicines guidance”. I have shared your report and our response with my colleague Yvonne Doyle.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 January 2021

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026