PFD report

Edward John Youde Barnard · Prevention of Future Deaths report

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Issued 21 Nov 2024•Inner South London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

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 An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Review schedule 2 controlled-drug requirements and decide whether to extend provisions to schedule 3 drugs through guidance.

    Stated by Royal College of Veterinary SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.
  2. Action

    Continue engaging with the Home Office on additional safeguards for controlled drugs used for veterinary euthanasia.

    Stated by Royal College of Veterinary SurgeonsStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2024.
  3. Action

    Require veterinary surgeons and nurses to securely lock quinalbarbitone and barbiturates using safe-custody-equivalent arrangements.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

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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

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

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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

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

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

Contact the Association of Police Controlled Drugs Liaison Officers to discuss possible coordinated actions and opportunities to strengthen working relationships.

Verbatim wording from the response

“There is also an Association of Police Controlled Drugs Liaison Officers (ACDLO) who we have met previously. We have given them presentations on our remit and the checks we conduct during vet practice inspections. Following this report, I will contact them to discuss whether any further actions are possible in coordination with them and whether there are any opportunities to further strengthen our working relationships.”

Source location

Response from Veterinary Medicines Directorate
Page 3 · response
Published 26 November 2024

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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

Conduct risk-based inspections checking veterinary practices’ and wholesalers’ compliance, including controlled-drug storage, access and supply requirements.

Verbatim wording from the response

“The Royal College of Veterinary Surgeons (RCVS) has also published very useful guidance online for controlled drugs where they state that whilst ████████ is not subject to safe custody requirements, it should be kept locked in a suitable controlled drugs cabinet when not in use. We echo that guidance and during inspections we ensure vets are aware that they are responsible for these products, that they are stored appropriately, and access is only given to persons they have authorised to have access.”

Source location

Response from Veterinary Medicines Directorate
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

Produce and publish a blog article reminding veterinary professionals of their responsibilities for ordering, storing, supplying and using controlled drugs.

Verbatim wording from the response

“We do provide guidance on the use and storage of veterinary controlled drugs on our website and are producing an article which we aim to publish shortly on our blog page reminding vets of their responsibilities when ordering, storing, supplying and using controlled drugs.”

Source location

Response from Veterinary Medicines Directorate
Page 1 · response
Published 26 November 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Explore ways to communicate legal and regulatory requirements for lethal medicines, including signposting advisory and support services.

    Stated by Royal College of Veterinary SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.
  2. 2

    Include a link to Vetlife’s independent emotional, financial and mental-health support in veterinary practice inspection reports.

    Stated by Veterinary Medicines DirectorateStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Home Office is responsible for legislation governing controlled drugs, including veterinary use.

    Stated by Veterinary Medicines DirectorateRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The respondent has no regulatory powers to amend controlled drugs legislation.

    Stated by Veterinary Medicines DirectorateOutside remitThe respondent said that this matter was outside its role or authority.

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

Explore ways to communicate legal and regulatory requirements for lethal medicines, including signposting advisory and support services.

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

Include a link to Vetlife’s independent emotional, financial and mental-health support in veterinary practice inspection reports.

Verbatim wording from the response

“We also include a link to the Vetlife website in our inspection reports to vet practices. Vetlife is a charity that provides independent, confidential and free emotional, financial and mental health support to the veterinary community including veterinary nurses, students and non-clinical staff.”

Source location

Response from Veterinary Medicines Directorate
Page 1 · response
Published 26 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 legislation governing controlled drugs, including veterinary use.

Verbatim wording from the response

“However, we should explain that the Home Office is responsible for the legislation regarding controlled drugs. That includes controlled drugs used for veterinary purposes and/or human use. The VMD has no regulatory powers to make changes to controlled drugs legislation.”

Source location

Response from Veterinary Medicines Directorate
Page 1 · response
Published 26 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 respondent has no regulatory powers to amend controlled drugs legislation.

Verbatim wording from the response

“However, we should explain that the Home Office is responsible for the legislation regarding controlled drugs. That includes controlled drugs used for veterinary purposes and/or human use. The VMD has no regulatory powers to make changes to controlled drugs legislation.”

Source location

Response from Veterinary Medicines Directorate
Page 1 · response
Published 26 November 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026