Overview
- The inquest concluded in early June 2026 that Isabelle Sapherson‑Moralee died as a result of misadventure and that her regular, sustained ketamine use played a very significant role in her death.
- A post‑mortem recorded respiratory depression from combined severe morphine and gabapentin toxicity and found biliary sepsis linked to ketamine‑related chronic liver disease.
- The coroner heard Ms Sapherson‑Moralee began frequent ketamine use around the 2020 lockdowns and suffered ketamine bladder, incontinence, severe weight loss and chronic pain that led to long‑term opioid prescriptions.
- Her family and the coroner raised concerns about repeated health‑service contacts, disputed capacity assessments and missed chances to escalate care or detain under the Mental Health Act.
- Official data cited at the inquest showed ketamine use in 16–59 year olds rose roughly 252% between 2014–15 and 2024–25, and charities warned low cost and easy access can trap users in a cycle of pain and increased use, which has renewed debate over reclassifying the drug.