A coroner has ruled that a prescription for medicinal cannabis likely contributed to the death of a 34-year-old man, in what is believed to be the first ruling of its kind since the drug was legalised for medical use.
HM Area Coroner Catherine McKenna concluded that Oliver Robinson’s death in November 2023 was misadventure. She found his prescription, first issued by the private Curaleaf Clinic in May 2022, “probably contributed to his death” and “acted as an obstacle” to him receiving appropriate psychiatric and addiction care. The court accepted the death was multi-factorial, involving longstanding depression and psycho-social stressors, but ruled the prescription reinforced his dependency and belief that cannabis was essential.
Campaign for ‘Oliver’s Law’
Now, Oliver’s brother, Alexander Robinson, is launching a campaign for tighter controls on UK private cannabis clinics, warning that without change, his brother will not be the last to be harmed. “Oliver’s Law” calls for a ban on prescribing to patients with serious mental illness, mandatory consultation with NHS mental health teams, and face-to-face assessments for complex cases instead of video consultations.
The campaign also demands tougher oversight by the Care Quality Commission (CQC), including routine audits and publication of prescribing data, mandatory reporting of serious harms, and clearer General Medical Council (GMC) sanctions for unsafe prescribing. Alexander Robinson argues the current safeguards are insufficient for vulnerable psychiatric patients.
Legal Landscape and a Rapidly Expanding Market
Medicinal cannabis was legalised in the UK in 2018. Specialist doctors on the GMC’s register can prescribe cannabis-based medicinal products (CBMPs) where they deem it clinically appropriate, in both NHS and private settings.
However, a stark divide exists in access. The NHS prescribes only a small number of licensed CBMPs, typically for severe epilepsy, multiple sclerosis, and chemotherapy-related pain, with approximately 5,000 such prescriptions in 2023. In contrast, private clinics prescribe far more widely. Data from the NHS Business Services Authority shows 659,293 unlicensed cannabis products were privately prescribed in 2024, more than double the 282,920 issued in 2023. An estimated 80,000 people in the UK are thought to hold a private prescription, with fewer than 5% of all medical cannabis prescriptions coming from the NHS.
The CQC, which regulates private clinics, states most privately prescribed products are unlicensed, meaning they have not been approved by the medicines regulator. Curaleaf Clinic, which prescribed to Oliver Robinson, was rated “Good” overall by the CQC in a 2024 inspection, with an “Outstanding” rating in the ‘Well-led’ category.
A Case Built on Incomplete Information
Oliver Robinson, a former property developer from Bury, had a long history of depression and addiction, including inpatient treatment at the Priory hospital where he was diagnosed with recurrent depressive disorder. He had used cannabis since adolescence, with addictive behaviours identified as a significant factor affecting his mood.
After leaving the Priory, he found temporary relief from depressive symptoms by using old cannabis he found at home. He subsequently signed up with Curaleaf Clinic. In May 2022, he underwent a video consultation with Dr Urmila Bhoskar, a child and adolescent psychiatrist, providing a GP summary that was nine months old. Curaleaf’s multidisciplinary team agreed a trial of medical cannabis was appropriate.
The coroner’s report later identified critical failings: the prescribing decision was based on an “out-of-date GP summary care record” and “incomplete information”. It noted Dr Bhoskar “had no consultant level experience in treating adult patients with Oliver’s complex presentation”. Furthermore, Curaleaf “did not communicate directly” with Oliver’s NHS or private psychiatrists once aware he was receiving other care.
The medicinal cannabis prescribed was especially potent, containing up to 27% tetrahydrocannabinol (THC), the psychoactive compound, compared to an estimated 15-20% in typical street cannabis.
Deterioration and a Family’s Helplessness
Alexander Robinson described the subsequent 11 months as “the most traumatic and hellish of my life”. Oliver’s behaviour became violently erratic, leading to regular police call-outs. He threatened to firebomb the family home, and his mother was classified as a victim of domestic abuse, obtaining a restraining order.
Oliver, unable to live at home, lost his job, took out a payday loan to fund prescriptions costing up to £1,000 a month, and at times lived in a tent. He became fixated on his prescription, aggressively dismissing concerns. “I have 11 months of emails and WhatsApp messages that are not my brother,” Alexander said. “They are the angriest and most vitriol-filled messages I have ever read.”
After the firebomb threat, the family wrote to Oliver’s former Priory therapist, Dr Justin Haslam, who had been told by Oliver that he supported the cannabis use. Dr Haslam replied that he was “gravely concerned”, believed Oliver needed more acute care, and referred him to NHS psychiatry. An NHS psychiatrist in Bury later diagnosed bipolar disorder, depression and cannabis dependency, warning cannabis was contributing to his deterioration, but Oliver rejected the diagnosis.
Expert testimony at the inquest from psychiatrist Dr Pavan Chahl underscored the clinical mismatch. He stated that under British National Formulary guidance, medicinal cannabis should not be prescribed to someone with a history of severe psychiatric disorder. “There is a lack of evidence for efficacy in depression and evidence it can cause or worsen depression. On this evidence, Oliver Robinson should never have been prescribed medicinal cannabis,” he said.
Regulatory Reckoning
The coroner has issued a Prevention of Future Deaths report to Curaleaf Clinic, which must respond by 23 April. Dr Bhoskar is to be referred to the GMC. The report was also sent to the CQC. A CQC spokesperson said while they were not a named recipient, they were “reviewing the report to consider if any regulatory action is needed.”
In a statement, Curaleaf Clinic said: “We note the specific proposals set out by the campaign. Questions of regulatory policy are a matter for the relevant bodies, including the CQC, MHRA and GMC. Curaleaf Clinic will engage constructively with any review or consultation that aims to strengthen patient safety across the sector.”
For Alexander Robinson, the case exposes a system where profit and patient safety are in conflict, and where the evidence for treating conditions like depression with cannabis is virtually non-existent. “If things do not change he is not going to be the last,” he said.