A man with a “dependence on cannabis” took his own life after being prescribed the drug by a private clinic using “out-of-date” GP records, a coroner has found.
According to a prevention of future deaths report published on February 10, Oliver Robinson was 34 when he died in 2023, with the coroner concluding that his death was “by misadventure”.
The report said Robinson had a “background history of addictive tendencies” including “excessive cannabis use”, and a “physical and psychological dependence on cannabis” which he obtained illicitly and through private prescriptions from Curaleaf Clinic.
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The court also found that the “emotional dysregulation” Robinson was experiencing at the time of his death was caused by “multiple factors” including “conflicts with housing and NHS services, debt” and his cannabis dependence.
Robinson enrolled on Curaleaf Clinic’s UK Medical Cannabis Registry research study in April 2022, it added, and received medicinal cannabis prescriptions “for the treatment of treatment-resistant depression” between May 7, 2022 and November 17, 2023.
“Addictive behaviours”
The report said that while under care at the Priory Clinic between September 2019 and September 2022, a consultant psychiatrist diagnosed Robinson with depression - but “was of the view” that by early 2022, his “addictive behaviours were the larger problem impacting on his mood”.
It added that he had “declined the addictions programme” offered to him by the psychiatrist at that time.
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Following an assessment by an NHS consultant psychiatrist in April 2023, Robinson received a “dual diagnosis” of “recurrent depressive disorder and mental and behavioural disorder due to cannabinoid dependency”, the coroner said.
“Notwithstanding this context, Curaleaf Clinic continued to issue prescriptions for medicinal cannabis to [Robinson]”, she added.
Coroner’s concerns
The coroner said the inquest into Robinson’s death “revealed matters giving rise to concern” and warned of a “risk that future deaths will occur unless action is taken”.
She noted that the consultant psychiatrist who reviewed Robinson at Curaleaf Clinic “had no consultant-level experience in treating adult patients” with his “complex presentation” or “in the type of treatments available for adult patients with treatment-resistant depression”.
“Treatment options had not been exhausted at the time that medicinal cannabis was prescribed,” she added.
C+D understands Curaleaf has addressed the issue of the prescribing clinician’s experience in its Regulation 28 response to the coroner’s findings, which will be made public in due course.
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The coroner also found that Curaleaf Clinic’s initial prescribing decision “was based on an out-of-date GP summary care record” and “without the knowledge” that Robinson “was under the care of a consultant psychiatrist at the Priory”.
“As such, the prescribing decision was based on incomplete information,” she said.
She added that once Curaleaf Clinic “became aware” that Robinson had been reviewed by consultant psychiatrists at the Priory and the NHS, it “did not communicate directly with them or seek to inform themselves of the treating psychiatrists’ views”.
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And she said the “continuation of prescriptions for medicinal cannabis acted as an obstacle” to Robinson “receiving appropriate psychiatric and addictions care”.
The coroner concluded that it was her opinion that “action should be taken to prevent future deaths” and that Curaleaf Clinic has “the power to take such action”.
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Curaleaf Clinic said “this is a truly tragic situation” and that its “thoughts remain with Mr Robinson’s family and everyone affected by his death”.
“We note the coroner’s conclusion of death by misadventure, and the recognition that this occurred in the context of multiple contributing factors,” it added. “Cases involving mental health are complex and deeply distressing, and we respect the important role of the inquest in examining the circumstances surrounding Mr Robinson’s death.”
It said it has “carefully considered the recommendations arising from the inquest and have responded in line with the required process”.
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“Our priority remains providing responsible, clinically led care within established medical and regulatory frameworks.”
“Out of respect for the family and patient confidentiality, it would not be right to comment further on the individual circumstances of this case. Our focus remains on supporting patients safely and responsibly.”
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