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NHS England will review its lack of prescribing guidance for patients with ketamine bladder syndrome in primary care, it has said in response to a coroner’s Prevention of Future Deaths (PFD) report.
The PFD report, from the Dorset coroner, dated 18 June 2026 and published on 15 September 2026, said that Isabelle Bridie Sapherson-Moralee died of combined severe morphine and gabapentin toxicity, alongside biliary sepsis owing to severe ketamine-related chronic liver disease.
Sapherson-Moralee experienced ketamine bladder syndrome (also known as ketamine urinary tract syndrome), chronic liver disease and chronic pain caused by long-term sustained ketamine use. The condition affects about three in ten ketamine users and causes damage to the bladder, urinary tract and kidneys.
She was prescribed morphine and gabapentin for pain relief, and the coroner concluded that “it seems likely that on the day of her death, with the intention of relieving her pain, Isabelle took too much medication, which, on a background [of] biliary sepsis caused by severe ketamine-related chronic liver disease, caused her death”.
The coroner, Brendan Joseph Allen, raised concerns that: “There are no prescribing guidelines to assist those in primary care who are prescribing analgesia for patients suffering ketamine bladder syndrome where there are concerns about concurrent ketamine use. The absence of guidelines presents a challenging scenario for both prescribers and patients.”
In its response to the coroner, NHS England acknowledged “there aren’t currently any prescribing guidelines for ketamine bladder syndrome in primary care”, although it noted an update produced by the British Journal of General Practice in 2023.
“However, in light of this case, the lack of guidance will be reviewed in relation to pain management in patients using non-prescribed ketamine and/or experiencing ketamine use disorder, and in line with the holistic guidance above,” NHS England added.
It also noted that in Sapherson-Moralee’s area, a new local care pathway for ketamine bladder has been developed between west Dorset involving Dorset County Hospital urology services, drug charity Reach and the community pain service. Similar work is being undertaken in east Dorset, it said.
Pan-Dorset primary care guidance has been developed, which made recommendations for prescribing for pain associated with ketamine use, and outlined the importance of timely referral to urology and drug and alcohol treatment services, NHS England said.
Community Pharmacy Dorset has sent a communication to local pharmacies highlighting the symptoms of ketamine bladder, which can mimic a urinary tract infection, and stressing the need for GP review where an individual is using ketamine.
UK ketamine use has increased significantly in recent years, particularly among young people, with above-average use recorded in the south-west of England. The number of people accessing treatment services for help with ketamine use in Dorset, Bournemouth, Christchurch and Poole increased four-fold since 2021, Dorset Council has said.
The PFD report, along with the NHS England and Department of Health and Social Care (DHSC) responses, stressed the need for a joined-up approach among the multiple services that ketamine users are likely to engage with.
In its response, the DHSC said it considered that the current framework provides nationally recognised clinical guidance through the Orange Book; access to prescribing and drug interaction information through the British National Formulary and other established medicines information resources; and access to specialist addiction services that can support prescribers in the management of patients with complex substance misuse histories.
However, it said it was “working to ensure information can be shared more easily between local authority commissioned drug and alcohol treatment services and NHS services”.
It also said it has “commissioned research examining patterns of ketamine use and the characteristics of people who use ketamine”.
“The study is expected to conclude in 2027 and gather qualitative data from people who use ketamine, people experiencing ketamine-related harms, and individuals both receiving and not receiving treatment. The research will improve understanding of the motivations for ketamine use, determinants of dependence, barriers to accessing treatment, routes to recovery and unmet treatment needs. The findings will help inform future policy and service development,” the DHSC said in its response to the PFD report.
