PFD report

James Patrick Boland · Prevention of Future Deaths report

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Issued 5 Nov 2024•Manchester South

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Maintaining ketamine as a Class B drug despite its serious harms
    Part of recurring concern: Failure to communicate the serious harms of ketaminePart of recurring concern: Unreliable regulatory control of dangerous psychoactive substances
  2. Illicit ketamine use causing severe long-term and potentially fatal health problems
    Part of recurring concern: Failure to communicate the serious harms of ketamine
  3. Lack of user understanding of ketamine’s health risks
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

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. ”

Is this part of a recurring concern?

Yes — Failure to communicate the serious harms of ketamine; Unreliable regulatory control of dangerous psychoactive substances.

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

Illicit ketamine use causing severe long-term and potentially fatal health problems

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. ”

Is this part of a recurring concern?

Yes — Failure to communicate the serious harms of ketamine.

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

Lack of user understanding of ketamine’s health risks

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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.1

  1. 1

    Commission the Advisory Council on the Misuse of Drugs to conduct an updated assessment of ketamine’s harms.

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.

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

Commission the Advisory Council on the Misuse of Drugs to conduct an updated assessment of ketamine’s harms.

Verbatim wording from the response

“I recognise growing concern about the harms of ketamine. I intend to commission the ACMD to conduct an updated harms assessment of ketamine as part of the forthcoming three-year work programme commission cycle.”

Source location

Response from The Home Office
Page 2 · response
Published 5 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

Data last updated 7 September 2026