Recipient

Royal College of Veterinary Surgeons

First report 14 Nov 2024•Latest report 21 Nov 2024

Recipient record

Reports, concerns and published responses

Other public bodies · Health and care professional regulator. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 5
Stated actions: 23

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

23stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Royal College of Veterinary Surgeons linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 Nov2024
Inner South London
Concerns raised2
1. Use of veterinary medicines for suicide by humans
2. Availability of veterinary-only substances through illicit sources
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Review schedule 2 controlled-drug requirements and decide whether to extend provisions to schedule 3 drugs through guidance.
  Stated planned
2. Action
  Continue engaging with the Home Office on additional safeguards for controlled drugs used for veterinary euthanasia.
  Stated in progress
3. Action
  Require veterinary surgeons and nurses to securely lock quinalbarbitone and barbiturates using safe-custody-equivalent arrangements.
  Stated completed
1. Action
  Advise practices to return controlled drugs to their cabinets for overnight storage wherever possible.
  Stated completed
2. Action
  Consider adding Practice Standards Scheme requirements for practices to maintain individualised suicide prevention plans.
  Stated planned
3. Action
  Review guidance on returning controlled drugs to practices when veterinary professionals are off duty.
  Stated planned
AI-generated summary

Edward John Youde Barnard · 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

Edward John Youde Barnard was found deceased in a hotel room on 9 January 2024 after taking a substance described as causing a fatal overdose, with the death concluded to be suicide. The principal concern was that a vulnerable young adult obtained a substance licensed for veterinary use from an illicit source, creating a potential emerging risk of its use in suicide.

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. The report was sent to Royal College of Veterinary Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Use of veterinary medicines for suicide by humans
Wider context from the report
“On completion of the inquest, I was concerned that Edward, a vulnerable young adult, managed to come into possession of ████████ a substance which I understand from the Toxicology report, is only licensed for use on animals by qualified veterinary professionals. I infer from the Toxicology evidence and the fact that Edward was not a veterinary professional that he must have obtained the substance from an illicit source. I am concerned that if I do not make a report a potential emerging risk to life may slip past public attention unnoticed. I therefore make this report to the Veterinary Medicines Directorate, whom I understand is the organisation responsible for licensing ████████ so that the Directorate is aware that the drug has been used for a suicidal purpose and to enable the organisation to examine any available preventive measures to reduce the risk of this suicide method occurring in future. I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society to take any available preventive measures to reduce the risk of this suicide method in future. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Veterinary Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Availability of veterinary-only substances through illicit sources
Wider context from the report
“On completion of the inquest, I was concerned that Edward, a vulnerable young adult, managed to come into possession of ████████ a substance which I understand from the Toxicology report, is only licensed for use on animals by qualified veterinary professionals. I infer from the Toxicology evidence and the fact that Edward was not a veterinary professional that he must have obtained the substance from an illicit source. I am concerned that if I do not make a report a potential emerging risk to life may slip past public attention unnoticed. I therefore make this report to the Veterinary Medicines Directorate, whom I understand is the organisation responsible for licensing ████████ so that the Directorate is aware that the drug has been used for a suicidal purpose and to enable the organisation to examine any available preventive measures to reduce the risk of this suicide method occurring in future. I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society to take any available preventive measures to reduce the risk of this suicide method in future. ”
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
Review schedule 2 controlled-drug requirements and decide whether to extend provisions to schedule 3 drugs through guidance.

Verbatim wording from the response
“Action | Date 1 | Relevant RCVS committees to consider additional Core requirement(s) in the RCVS Practice Standards Scheme for practices to have individualised suicide prevention plans. The aim being to prevent incidents and protect staff and the wider public. | February 2025 2 | RCVS Standards Committee to review the legislative requirements for schedule 2 CDs and decide what (if any) provisions may be extended to schedule 3 CDs via RCVS guidance, for example, requirement to record use in the CD register. | February 2025”

Source location
Response from RCVS
Page 2 · response
Published 26 November 2024
Open published response
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
Continue engaging with the Home Office on additional safeguards for controlled drugs used for veterinary euthanasia.

Verbatim wording from the response
“Action | Date 3 | RCVS Standards Committee to review the guidance on returning CDs to the practice when off duty. | February 2025 4 | Explore methods of communicating the legal and regulatory requirements relating to lethal medicines to the profession (e.g. via RCVS Academy, the RCVS online continuing professional development portal), including signposting to advisory/support services. | Spring 2025 5 | Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine. | Ongoing”

Source location
Response from RCVS
Page 3 · response
Published 26 November 2024
Open published response
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
Require veterinary surgeons and nurses to securely lock quinalbarbitone and barbiturates using safe-custody-equivalent arrangements.

Verbatim wording from the response
“4. Before moving on to the specific issues raised regarding veterinary medicines, it may be of assistance to set out some background. Whilst research suggests that suicidal ideation is not higher in the veterinary profession as compared to the general population, the likelihood of completion is higher due to knowledge of, and access to, lethal means. Prevention and reduction of suicide in the veterinary professions has therefore been an area of focus in many aspects of our work in recent years, and naturally increased safeguards around veterinary medicines used for euthanasia have been a key part of this work. As such, whilst Mr Barnard was not a veterinary surgeon or veterinary nurse himself, we believe our ongoing work is relevant to the issues raised in this inquiry.”

Source location
Response from RCVS
Page 1 · response
Published 26 November 2024
Open published response
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
Advise practices to return controlled drugs to their cabinets for overnight storage wherever possible.

Verbatim wording from the response
“8. In addition, we advise that, wherever possible, CDs should be returned to the CD cabinet at the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small animal), 8.1.12 (farm animal), 9.1.12 (equine).) As well as restricting access by veterinary surgeons when they are not on duty, this guidance aims to reduce the risk of drugs being stolen from vehicles and entering the illegal market.”

Source location
Response from RCVS
Page 2 · response
Published 26 November 2024
Open published response
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
Consider adding Practice Standards Scheme requirements for practices to maintain individualised suicide prevention plans.

Verbatim wording from the response
“Action | Date 1 | Relevant RCVS committees to consider additional Core requirement(s) in the RCVS Practice Standards Scheme for practices to have individualised suicide prevention plans. The aim being to prevent incidents and protect staff and the wider public. | February 2025 2 | RCVS Standards Committee to review the legislative requirements for schedule 2 CDs and decide what (if any) provisions may be extended to schedule 3 CDs via RCVS guidance, for example, requirement to record use in the CD register. | February 2025”

Source location
Response from RCVS
Page 2 · response
Published 26 November 2024
Open published response
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
Review guidance on returning controlled drugs to practices when veterinary professionals are off duty.

Verbatim wording from the response
“Action | Date 3 | RCVS Standards Committee to review the guidance on returning CDs to the practice when off duty. | February 2025 4 | Explore methods of communicating the legal and regulatory requirements relating to lethal medicines to the profession (e.g. via RCVS Academy, the RCVS online continuing professional development portal), including signposting to advisory/support services. | Spring 2025 5 | Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine. | Ongoing”

Source location
Response from RCVS
Page 3 · response
Published 26 November 2024
Open published response
14 Nov2024
Hampshire, Portsmouth and Southampton
Concerns raised3
1. Failure to verify the stated need for potentially lethal drugs through independent veterinary scrutiny
2. Lack of adequate controls over veterinary surgeons' access to potentially lethal drugs
3. Failure to prevent unaccompanied removal of potentially lethal drugs from the veterinary surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Issue guidance requiring veterinary surgeons and nurses to securely lock away schedule 3 barbiturates.
  Stated completed
2. Action
  Continue engaging with the Home Office on implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine.
  Stated in progress
3. Action
  Review guidance on returning controlled drugs to practices when veterinary professionals are off duty.
  Stated planned
1. Action
  Review schedule 2 controlled-drug legislative requirements and decide whether provisions should be extended to schedule 3 drugs through RCVS guidance.
  Stated planned
2. Action
  Advise practices to return controlled drugs to their controlled-drugs cabinet for overnight storage wherever possible.
  Stated completed
Respondent positions 2
1. Position
  The Home Office is responsible for the legislation governing controlled drugs.
  Redirects responsibility
1. Position
  A universal two-person rule for euthanasia drugs is impractical for rural and ambulatory practitioners and could harm animal welfare.
  Unable to act
AI-generated summary

John Robert ELLIS · 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

John Robert ELLIS, a veterinary surgeon experiencing personal, financial and work-related stress, died after self-administering a toxic quantity of a drug he had obtained by falsely claiming it was needed to euthanise a dog. The principal concern was that veterinary surgeons could access potentially lethal controlled drugs without adequate verification, scrutiny or safeguards against misuse.

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. The report was sent to Royal College of Veterinary Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Failure to verify the stated need for potentially lethal drugs through independent veterinary scrutiny
Wider context from the report
“Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Veterinary Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Lack of adequate controls over veterinary surgeons' access to potentially lethal drugs
Wider context from the report
“Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Veterinary Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent unaccompanied removal of potentially lethal drugs from the veterinary surgery
Wider context from the report
“Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”
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
Issue guidance requiring veterinary surgeons and nurses to securely lock away schedule 3 barbiturates.

Verbatim wording from the response
“11. In light of the known risk factors, the RCVS consistently goes beyond what is required by legislation with the aim of reducing misuse of drugs, including controlled drugs. For example, although quinabibartone (aka Somulose) is a schedule 2 controlled drug (CD), it is exempted from the safe custody in the legislation. In February 2023, we issued guidance requiring that veterinary surgeons and veterinary nurses lock quinalbarbitone away in a manner equivalent to ‘safe custody’, i.e. specific requirements for safe storage of certain CDs as set out in the regulations cited above. Similarly, the barbiturates (including ████████) are schedule 3 CDs and as such, not subject to safe custody under the relevant legislation. Again, in 2021 we issued guidance requiring veterinary surgeons and veterinary nurses to securely lock them away.”

Source location
Response from RCVS
Page 2 · response
Published 15 November 2024
Open published response
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
Continue engaging with the Home Office on implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine.

Verbatim wording from the response
“5 | Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine. | Ongoing”

Source location
Response from RCVS
Page 4 · response
Published 15 November 2024
Open published response
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
Review guidance on returning controlled drugs to practices when veterinary professionals are off duty.

Verbatim wording from the response
“17. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. Following this review, the actions set out in the table below have been agreed.”

Source location
Response from RCVS
Page 3 · response
Published 15 November 2024
Open published response
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
Review schedule 2 controlled-drug legislative requirements and decide whether provisions should be extended to schedule 3 drugs through RCVS guidance.

Verbatim wording from the response
“17. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. Following this review, the actions set out in the table below have been agreed.”

Source location
Response from RCVS
Page 3 · response
Published 15 November 2024
Open published response
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
Advise practices to return controlled drugs to their controlled-drugs cabinet for overnight storage wherever possible.

Verbatim wording from the response
“12. In addition, we advise that, wherever possible, controlled drugs should be returned to the controlled drugs cabinet at the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small animal), 8.1.12 (farm animal), 9.1.12 (equine)).”

Source location
Response from RCVS
Page 2 · response
Published 15 November 2024
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
The Home Office is responsible for the legislation governing controlled drugs.

Verbatim wording from the response
“10. Regarding veterinary medicines, it should be noted that many of the requirements around controlled drugs are set out in the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) Regulations 1973. As you will know, the Home Office is the relevant government department with responsibility for this legislation.”

Source location
Response from RCVS
Page 2 · response
Published 15 November 2024
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
A universal two-person rule for euthanasia drugs is impractical for rural and ambulatory practitioners and could harm animal welfare.

Verbatim wording from the response
“14. As you will appreciate, access to and knowledge of how to use lethal medicines is a necessary part of a veterinary surgeon’s role. As such, in terms of barriers to access, there is a balance to be struck between keeping the veterinary team safe and ensuring animal health and welfare is protected. For example, one suggestion has been that the RCVS should”

Source location
Response from RCVS
Page 2 · response
Published 15 November 2024
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Use of veterinary medicines for suicide by humans

Availability of veterinary-only substances through illicit sources

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised3

Failure to verify the stated need for potentially lethal drugs through independent veterinary scrutiny

Lack of adequate controls over veterinary surgeons' access to potentially lethal drugs

Failure to prevent unaccompanied removal of potentially lethal drugs from the veterinary surgery

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 6

Actions described in response 5

Respondent positions 2