PFD report

John Robert ELLIS · Prevention of Future Deaths report

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Issued 14 Nov 2024•Hampshire, Portsmouth and Southampton

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

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. Failure to verify the stated need for potentially lethal drugs through independent veterinary scrutiny
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
  2. Lack of adequate controls over veterinary surgeons' access to potentially lethal drugs
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
  3. Failure to prevent unaccompanied removal of potentially lethal drugs from the veterinary surgery
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
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.5

  1. Action

    Issue guidance requiring veterinary surgeons and nurses to securely lock away schedule 3 barbiturates.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  2. Action

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

    Stated by Royal College of Veterinary SurgeonsStated in progressThe respondent said that this action was in progress when they made their response on 15 November 2024.
  3. Action

    Review guidance on returning controlled drugs to practices when veterinary professionals are off duty.

    Stated by Royal College of Veterinary SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The Home Office is responsible for controlled-drugs legislation, and the Veterinary Medicines Directorate cannot change it.

    Stated by Veterinary Medicines DirectorateRedirects 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

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. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

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 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. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

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

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. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

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 controlled-drugs legislation, and the Veterinary Medicines Directorate cannot change it.

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 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

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.12

  1. 1

    Produce an article reminding veterinarians of their responsibilities for ordering, storing, supplying and using controlled drugs.

    Stated by Veterinary Medicines DirectorateStated in progressThe respondent said that this action was in progress when they made their response on 15 November 2024.
  2. 2

    Conduct a survey of veterinary students and professionals on disability, chronic illness, neurodiversity and mental health to inform future policies and activities.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  3. 3

    Provide free-to-access Academy training promoting healthy workplace cultures, leadership, management and psychological safety.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  4. 4

    Explore methods to communicate legal and regulatory requirements for lethal medicines and signpost advisory and support services to the profession.

    Stated by Royal College of Veterinary SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.
  5. 5

    Consider adding Practice Standards Scheme Core requirements for practices to maintain individualised suicide-prevention plans.

    Stated by Royal College of Veterinary SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.
  6. 6

    Provide free or subsidised Mental Health First Aid and civility training for veterinary professionals.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  7. 7

    Run the Mind Matters Initiative to support veterinary professionals’ mental health through systemic change, research, training and resources.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  8. 8

    Engage with overseas bodies and regulators to share best practice and promote access to mental health support.

    Stated by Royal College of Veterinary SurgeonsStated in progressThe respondent said that this action was in progress when they made their response on 15 November 2024.
  9. 9

    Provide financial support to Vetlife and Vet Support so they can offer confidential assistance to veterinary professionals in need.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  10. 10

    Issue guidance requiring veterinary surgeons and nurses to store quinalbarbitone securely as if subject to safe-custody requirements.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  11. 11

    Require participating practices to address workplace mental health, provide line-manager guidance and display mental health and wellbeing resources through Practice Standards Scheme accreditation.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
  12. 12

    Promote access to mental health and wellbeing support through universities, colleges and veterinary conferences.

    Stated by Royal College of Veterinary SurgeonsStated completedThe respondent said that this action was complete when they made their response on 15 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

Produce an article reminding veterinarians 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 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

Conduct a survey of veterinary students and professionals on disability, chronic illness, neurodiversity and mental health to inform future policies and activities.

Verbatim wording from the response

“5. The RCVS takes supporting mental health within the profession very seriously, and, as well as taking steps to be a compassionate regulator and minimise the impact of our complaints process on veterinary practitioners, we have also run the Mind Matters Initiative (MMI) for the last ten years. MMI aims to support the mental health and wellbeing of all members of the veterinary team, by supporting systemic change, and the research needed to underpin it, as well as providing training and resources to protect mental health and help veterinary team members to thrive.”

Source location

Response from RCVS
Page 1 · 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

Provide free-to-access Academy training promoting healthy workplace cultures, leadership, management and psychological safety.

Verbatim wording from the response

“7. Our RCVS Academy, in conjunction with our MMI and Leadership & Inclusion workstreams, has a variety of free-to-access training. Many of these courses promote a healthy and positive culture within practice, especially looking at leadership and management and unconscious bias, as these skills generate psychological safety within the workplace.”

Source location

Response from RCVS
Page 1 · 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

Explore methods to communicate legal and regulatory requirements for lethal medicines and signpost advisory and support services to the profession.

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

Consider adding Practice Standards Scheme Core requirements for practices to maintain individualised suicide-prevention plans.

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

Provide free or subsidised Mental Health First Aid and civility training for veterinary professionals.

Verbatim wording from the response

“6. We also financially support the independent organisations Vetlife and Vet Support, who offer confidential support to individuals in need. In addition, we provide free or heavily subsidised training in Mental Health First Aid and civility, and more is planned for the coming year. Furthermore, we spend a significant amount of time at universities, colleges and veterinary conferences to help normalise and destigmatise accessing mental health and wellbeing support. At an international level, senior leaders engage with overseas bodies and regulators on an ongoing basis to share best practice and latest insights, and to further promote accessing of mental health support.”

Source location

Response from RCVS
Page 1 · 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

Run the Mind Matters Initiative to support veterinary professionals’ mental health through systemic change, research, training and resources.

Verbatim wording from the response

“5. The RCVS takes supporting mental health within the profession very seriously, and, as well as taking steps to be a compassionate regulator and minimise the impact of our complaints process on veterinary practitioners, we have also run the Mind Matters Initiative (MMI) for the last ten years. MMI aims to support the mental health and wellbeing of all members of the veterinary team, by supporting systemic change, and the research needed to underpin it, as well as providing training and resources to protect mental health and help veterinary team members to thrive.”

Source location

Response from RCVS
Page 1 · 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

Engage with overseas bodies and regulators to share best practice and promote access to mental health support.

Verbatim wording from the response

“6. We also financially support the independent organisations Vetlife and Vet Support, who offer confidential support to individuals in need. In addition, we provide free or heavily subsidised training in Mental Health First Aid and civility, and more is planned for the coming year. Furthermore, we spend a significant amount of time at universities, colleges and veterinary conferences to help normalise and destigmatise accessing mental health and wellbeing support. At an international level, senior leaders engage with overseas bodies and regulators on an ongoing basis to share best practice and latest insights, and to further promote accessing of mental health support.”

Source location

Response from RCVS
Page 1 · 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

Provide financial support to Vetlife and Vet Support so they can offer confidential assistance to veterinary professionals in need.

Verbatim wording from the response

“6. We also financially support the independent organisations Vetlife and Vet Support, who offer confidential support to individuals in need. In addition, we provide free or heavily subsidised training in Mental Health First Aid and civility, and more is planned for the coming year. Furthermore, we spend a significant amount of time at universities, colleges and veterinary conferences to help normalise and destigmatise accessing mental health and wellbeing support. At an international level, senior leaders engage with overseas bodies and regulators on an ongoing basis to share best practice and latest insights, and to further promote accessing of mental health support.”

Source location

Response from RCVS
Page 1 · 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

Issue guidance requiring veterinary surgeons and nurses to store quinalbarbitone securely as if subject to safe-custody requirements.

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

Require participating practices to address workplace mental health, provide line-manager guidance and display mental health and wellbeing resources through Practice Standards Scheme accreditation.

Verbatim wording from the response

“9. Our Practice Standards Scheme (PSS) is a voluntary initiative to promote and maintain the highest standards of veterinary care. Whilst membership of the PSS is voluntary, around 66% of eligible UK practices are part of it. There are three different levels of accreditation a practice premises can apply for, depending on the type of premises, services offered, and species treated. Core level (the most basic level) covers RCVS Code of Professional Conduct requirements and legislation, and is applicable to all practices whether or not they are part of PSS. The following requirement is included at Core, and practices are required to evidence this as part of their PSS assessment:”

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

Promote access to mental health and wellbeing support through universities, colleges and veterinary conferences.

Verbatim wording from the response

“6. We also financially support the independent organisations Vetlife and Vet Support, who offer confidential support to individuals in need. In addition, we provide free or heavily subsidised training in Mental Health First Aid and civility, and more is planned for the coming year. Furthermore, we spend a significant amount of time at universities, colleges and veterinary conferences to help normalise and destigmatise accessing mental health and wellbeing support. At an international level, senior leaders engage with overseas bodies and regulators on an ongoing basis to share best practice and latest insights, and to further promote accessing of mental health support.”

Source location

Response from RCVS
Page 1 · response
Published 15 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