Recurring concern

Unreliable regulatory control of dangerous psychoactive substances

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First reported 6 Oct 2014•Latest report 5 Nov 2024

Definition

What this concern includes

Includes failures by legislative, regulatory or public-authority processes to classify, schedule, prohibit or otherwise establish effective domestic controls for dangerous synthetic, novel or other psychoactive substances, including delayed amendments and delayed proscription where the substance's serious harm is identified.

Not included

  • Excludes clinical recognition, treatment, ambulance response or overdose-management failures after exposure to a psychoactive substance.
  • Excludes ordinary illicit-drug supply, possession or access-control failures where the deficiency is not the legal or regulatory control of the substance itself.
  • Excludes regulatory controls for medicines, toxic chemicals or other hazards unless the assertion concerns a dangerous psychoactive substance.
  • Excludes general drug-policy or public-awareness concerns without an asserted failure to establish or maintain effective regulatory control.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office3
Department of Health and Social Care1
Ministry of Justice1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    James Patrick Boland · 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

    James Patrick Boland, known as Jamie, was found unresponsive at home on 19 June 2024 and died from sepsis caused by acute pyelonephritis, against a background of chronic ketamine use. The report raised concerns that ketamine use can cause severe long-term health problems, that users may perceive it as safer because it is classified as a Class B drug, and that increasing illicit use is linked to potentially fatal health problems.

    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

    Maintaining ketamine as a Class B drug despite its serious harms

    Wider context from the report

    “The inquest heard that previously Mr Boland had used cocaine a class A drug but, had switched to ketamine a class B drug on the basis that he perceived it to be less harmful. His perception that it was less harmful was based on the fact it is designated as a class B rather than Class A drug. The evidence before the inquest was that Ketamine is a deeply harmful substance when used outside the purposes for which it is licenced for prescribing by clinicians and that users such as Mr Boland are unable to give it up despite knowing how dangerous it is to their health. Maintaining its classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is “safer”. The evidence at the inquest was that Ketamine use causes huge long term life changing health problems. In Mr Boland’s case it had caused long term urological damage and liver damage. It was the damage to his urological system caused by Ketamine that led to his death. The inquest was told that there is a significant increase in the illicit use of Ketamine and that this has led to clinicians seeing a rise in potentially fatal health problems linked to its use. The extent of these risks rarely understood by users until the damage has been done to their health. ”

    Source location

    James Patrick Boland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Surrey

    AI-generated summary

    Victoria STOREY · 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

    Victoria Storey was found deceased in her bedroom on 3 September 2022 after taking an accidental overdose of a potent synthetic opioid that was not licensed for medicinal use. The report raised concerns that the substance was illicitly traded and marketed as common pharmaceutical opiates, that its contents were unknown to users, and that it was not then controlled under the relevant drug legislation despite its high risk of fatal overdose.

    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

    Failure to control potent synthetic opiates under Class A and Schedule 1

    Wider context from the report

    “- The Home Office requested advice from the Advisory Council on the Misuse of Drugs (ACMD) on the appropriate domestic control of ████████, and was advised by the ACMD on 18th July 2022 that ████████ (and other similar compounds) should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 and listed as Class A drugs under the Misuse of Drugs Act 1971. However, at present the Act and Regulations have not been amended to include ████████ and it is unclear if and when this will take place. ████████ is not therefore currently controlled under Class A, Schedule 1, Misuse of Drugs Act 1971 despite its heroin-like effects with a high risk of fatal overdose. ”

    Source location

    Victoria STOREY · Prevention of Future Deaths report
    Page 2 · 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

    Bring forward legislation to control 11 synthetic opioids under the Misuse of Drugs Act and associated Regulations.

    Verbatim wording from the response

    “The Government accepted these recommendations in February, committing to control 11 synthetic opioids, including ████████, under the 1971 Act and associated Regulations. In light of ongoing drug-related deaths and non-fatal overdoses associated with synthetic opioids in the UK, we intend to bring forward this legislation by the end of the year to come into force in early 2024. This letter can be found on GOV.UK here: Government response to the ACMD’s advice on 2-benzyl benzimidazole and piperidine benzimidazole opioids (publishing.service.gov.uk)”

    Source location

    Response from Home Office
    Page 1 · response
    Published 7 July 2023

    Open published response

    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

    Existing and planned measures are considered appropriate to reduce the risk of deaths involving synthetic opioids.

    Verbatim wording from the response

    “Given we are already in the process of controlling ████████, and the other measures which I have outlined above, I consider that appropriate measures to reduce the risk of deaths like this from happening are already coming into place. I hope that you agree with my assessment, and I would like to thank you for bringing this matter to my attention.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 7 July 2023

    Open published response

  3. Portsmouth and South East Hampshire

    AI-generated summary

    Matthew Alexander Flatman · 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

    Matthew Alexander Flatman died at Queen Alexandra Hospital, Portsmouth, on 5 July 2013 after experiencing chest, jaw and arm pain, followed by a cardiac arrest. The inquest recorded that he had taken MDAI, a so-called legal high, the previous evening, and concluded that its consumption precipitated a myocardial infarction and subsequent cardiac arrest in the context of severe coronary artery disease. The report raised concerns about the fatal risk posed by MDAI and the slow process of proscribing it as an illegal drug.

    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

    Delays in proscription of MDAI as an illegal drug

    Wider context from the report

    “(1) The "legal high" taken by Matthew Flatman was a substance known as Gogaine or MDAI. This substance is in the process of being proscribed as an illegal drug but the process is so very slow. (2) MDAI presents a fatal risk to all its users but particularly to those with cardiac problems and its proscription should be accelerated. ”

    Source location

    Matthew Alexander Flatman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026