PFD report

Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report

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Issued 18 Dec 2020•East Sussex

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised1

  1. Lack of Mental Health Professionals’ awareness of “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis
    Part of recurring concern: Inadequate controls for hallucinogen-related psychosis risks
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.4

  1. Action

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

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  2. Action

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

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  3. Action

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

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

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

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 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. ”

Is this part of a recurring concern?

Yes — Inadequate controls for hallucinogen-related psychosis risks.

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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

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

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 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 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

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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

    Provide targeted, ring-fenced funding and support to local partnerships delivering multi-agency suicide prevention, self-harm prevention and bereavement plans.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  2. 2

    Share learning and outputs from the regional team with suicide-prevention leads and teams nationally.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.

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

Provide targeted, ring-fenced funding and support to local partnerships delivering multi-agency suicide prevention, self-harm prevention and bereavement plans.

Verbatim wording from the response

“Reducing suicide and preventing self-harm is a key priority for NHS England/ Improvement. We are working closely with partners, including Public Health England and the Department of Health and Social Care to support local areas to deliver multi-agency suicide prevention plans. As part of the £2.3billion settlement for mental health in the Long Term Plan, we are providing targeted and ring-fenced funding to all Sustainability and Transformation Partnerships (STPs) so they can deliver their multi-agency plans. This includes suicide prevention activities, initiatives to prevent self-harm and putting in place postvention bereavement support. By 2023/24, this will total £57M additional investment in suicide prevention and bereavement.”

Source location

Response from NHS England
Page 1 · 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

Share learning and outputs from the regional team with suicide-prevention leads and teams nationally.

Verbatim wording from the response

“Furthermore, based on the insights provided in this report, the NHS E/I National team will share any outputs and learning generated by the South East regional team with all other suicide prevention regional leads and teams nationally.”

Source location

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

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