Words by Ben Stevens & Sarah Sinclair
A new campaign is calling for urgent regulatory changes to how medical cannabis is prescribed to psychiatric patients in the UK, following what is believed to be the first time a coroner has found that a prescription for cannabis contributed to a death in the country.
Oliver Robinson, 34, who had a dual diagnosis of recurrent depressive disorder and mental and behavioural disorder due to cannabinoid dependency, died in tragic circumstances in November 2023.
At an inquest concluding on 30 January 2026, Area Coroner Catherine McKenna recorded a finding of death by misadventure, following a period of acute emotional dysregulation driven by multiple factors.
McKenna found that the prescription of medical cannabis had contributed to Oliver’s dysregulation and ‘worsening mental state’, and was part of a ‘causal chain of events’ that ultimately led to his death.
Oliver’s Law, launched on 31st March by his family, is calling for statutory contraindications, mandatory psychiatric oversight, stronger enforcement from regulators like the Care Quality Commission (CQC) in the prescribing of cannabis-based medicines to patients with mental health conditions.
Speaking to Business of Cannabis and Cannabis Health, Oliver’s brother, Alexander Robinson, explained that the campaign was ‘not designed to attack medical cannabis’, recognising the ‘very clear benefits’ for conditions like MS, epilepsy, and chronic pain.’
The aim, he said, is to ‘make sure that it’s safe’ and to ensure that ‘other families don’t suffer in the same way’.
What the coroner’s report found
The coroner determined that the prescription of medical cannabis reinforced Oliver’s belief that cannabis was necessary for managing his condition, gave the substance a sense of legitimacy, and created barriers to the advice of other treating psychiatrists.
In the subsequent Regulation 28 Report to Prevent Future Deaths, four key issues were raised as ‘matters giving rise to concern’ that, in the coroner’s opinion, could lead to a risk of ‘future deaths unless action is taken’.
This included concerns around the experience of the prescribing clinician in treating adult patients with Oliver’s “complex presentation”, communication between the private clinic and Oliver’s other healthcare providers, and that the prescription acted as an “obstacle” to Oliver receiving appropriate psychiatric treatment.
In response, Curaleaf Clinic acknowledged that it was a ‘deeply tragic situation’ and said its thoughts were with everyone affected by Oliver’s death. It says it has ‘engaged seriously’ with the concerns and had already concluded a ‘comprehensive internal investigation and implemented material changes to our clinical governance, communication processes, and ongoing care before the commencement of the inquest’.
In a statement, a spokesperson for Curaleaf Clinic, said: “The Coroner concluded death by misadventure, finding Mr Robinson’s emotional dysregulation arose from multiple factors and psychosocial stressors. We respect the coronial process and have engaged with it fully, including through our published response to the Regulation 28 Prevention of Future Deaths report.
“Every prescribing decision at Curaleaf Clinic is made by a multidisciplinary team, not a single clinician, and is informed by an evidence base that we keep under continuous review. We are committed to responsible, safe practice and to strengthening our clinical governance in line with best practice.”
The matters raised by the coroner and the clinic’s response are set out in more detail at the bottom of this article, and can be read in full via the Regulation 28 report.
Oliver’s Law – eight key changes
Oliver’s family is now campaigning for eight key regulatory changes to how cannabis-based products are prescribed for psychiatric conditions.
This includes introducing statutory contraindications to prevent the prescribing of medical cannabis for patients with serious mental illness, such as bipolar disorder, schizophrenia, psychosis, or active suicidal ideation, mandatory consultation with NHS psychiatrists or mental health team before prescribing for any patient with a mental health history, and face-to-face assessment requirements for complex cases.
The family is also calling for more robust CQC oversight of private cannabis clinics, a centralised adverse event reporting system for medical cannabis through the MHRA, with mandatory reporting of serious harms, and clear guidance from the General Medical Council (GMC) that doctors prescribing outside their competence or missing documented contraindications will face fitness-to-practice consequences.
It comes as the Advisory Council for the Misuse of Drugs (ACMD) is reviewing the regulatory framework for prescribing CBPMs, with a view to understanding whether the legislation introduced in 2018 has had any “unintended consequences”.
In July 2025, the CQC’s controlled drugs annual report also highlighted concerns around prescribing for conditions with limited evidence, gaps in communication with NHS services, and insufficient specialist oversight.
“We’re not campaigning against medical cannabis,” said Alexander.
“We don’t want the pendulum to swing the other way completely. We think that it went slightly too far in the other direction to begin with, and that has led to some unsafe practices.”
Through engagement with the Home Office and Department of Health, as well as with parliamentarians across parties, he hopes to implement ‘clear, actionable targets that are ‘reasonable and relatively easy to implement’.
Curaleaf Clinic said it was aware of the proposals set out by the campaign, and it was a matter for the appropriate regulators.
“Questions of regulatory policy are a matter for the relevant bodies, including the CQC, MHRA and GMC,” a spokesperson said.
“Curaleaf Clinic has always operated within established clinical and regulatory frameworks and will continue to engage openly with regulators, clinicians, and patients to support high standards of care across the sector.”
The lack of evidence
The case also raises important questions about the lack of high-quality evidence for the treatment of depression and other mental health conditions with medical cannabis.
While patients frequently report benefits in real-world studies, a very limited number of randomised controlled trials have been conducted to understand long-term safety and efficacy.
A review published in The Lancet Psychiatry by a team of international researchers found a “scarcity of evidence” for the routine prescribing of cannabinoids in mental health and substance use disorders.
Alexander also raised concerns about the lack of research into contraindications and pharmacological interactions between cannabinoids and the type of antidepressant medication Oliver was taking.
“We don’t think there’s a strong enough evidence base to prescribe for these conditions right now, and there are various other checks and balances that should be in place,” he adds.
Patients call for a collective response
In a statement, the medical cannabis advocacy group, United Patients Alliance, expressed ‘sincere condolences’ to Oliver’s loved ones and said the inquest highlights the ‘critical importance of safe and appropriate prescribing, particularly where patients have complex mental health histories or known vulnerabilities’.
The organisation says a multi-agency review of medical cannabis clinics is needed to ‘raise the standards of prescriptions and patient care’ amid concerns that these recent developments may have a detrimental effect on the prescribing of medical cannabis to appropriate patients.
“These developments risk over‑emphasising potential harms, under‑stating areas of proven or emerging clinical benefit, and could drive a blunt, top‑down regulatory response that restricts access, increases stigma and deters clinicians from considering cannabis‑based treatments where they may be clinically indicated,” said a UPA spokesperson.
The group has also called for clinics, clinicians, professional bodies, and patient groups to agree on ‘proportionate standards for prescribing, risk assessment, and monitoring, and demonstrate professional leadership’.
“Rather than waiting for the government or regulators to impose further restrictions, UPA believes the sector must respond collectively now,” it added.
“This will ensure that any future regulatory changes are co‑designed with clinicians and patients, strengthening safety without undermining lawful, evidence‑based access to medical cannabis.”
Clinicians – patient safety must remain central to prescribing
The Medical Cannabis Clinicians Society (MCCS), which is currently updating its best practice guidelines for the prescribing of cannabis-based medicines, says that while medical cannabis can be a ‘safe and effective treatment’ when prescribed appropriately, like any controlled medicine, it requires ‘careful clinical oversight and robust governance’.
“Patient safety must remain central to every prescribing decision,” a spokesperson for the MCCS said.
“In more complex cases, particularly where there is a significant mental health history, this means thorough assessment, clear clinical reasoning, careful risk evaluation, and ongoing monitoring, ideally with multidisciplinary input.
“Medical cannabis is not appropriate in every circumstance. Prescribing decisions must be made cautiously, transparently, and within a well-governed clinical framework to minimise risk and ensure safe patient care.
“As a professional body, we are committed to supporting clinicians with clear, evidence-informed standards and continual improvement in practice.”
The Regulation 28 Report and clinic response
The Regulation 28 Report to Prevent Future Deaths identifies four key issues that were raised as ‘matters giving rise to concern’ that, in the coroner’s opinion, could lead to a risk of ‘future deaths unless action is taken’.
1 – The Consultant Psychiatrist who reviewed Oliver at Curaleaf specialised in Child and Adolescent Psychiatry and had no Consultant-level experience in treating adult patients or patients with Oliver’s complex needs. Furthermore, treatment options had not been exhausted before a prescription was given.
In response, Curaleaf said it ‘respectfully disagreed’ with concerns about the prescribing clinician’s experience and the exhaustion of treatment options, stating that all UK consultant psychiatrists complete extensive adult psychiatry training and that the clinician in question had several years of relevant adult experience.
The clinic also maintained that Oliver had already tried a wide range of conventional treatments and emphasised that current UK practice does not require all licensed treatments to be exhausted before prescribing cannabis-based medicines.
The prescribing decision was reviewed and approved at a multidisciplinary team meeting comprising consultants from multiple specialities alongside a specialist pharmacist.
2 – Curaleaf’s initial prescribing decision was based on an out-of-date GP summary care record and without the knowledge that Oliver was under the care of a Consultant Psychiatrist at the Priory.
Curaleaf said it did not accept that its prescribing decision was ‘materially flawed’ by reliance on an out-of-date Summary Care Record (SCR), noting the record was less than a year old and contained key clinical details, including Oliver’s diagnosis and prior treatments. The clinic said the prescribing clinician also took a detailed history directly from Oliver, who had capacity, and asked about any updates to his care, adding that private providers are reliant on how frequently NHS records are updated.
It stated that once aware of other clinicians involved, efforts were made to contact them, and that prescribing decisions were routinely communicated to Oliver’s GP, who was aware of the prescription, while the Priory was also informed via Oliver but raised no concerns. Curaleaf acknowledged SCR reliance as an area for improvement and said it has since implemented access to more up-to-date NHS records and now requires contact with Community Mental Health Teams before prescribing in such cases.
Challenges in relation to NHS integration and communication between private and NHS providers are frequently reported by prescribers, and many clinics have now integrated the ‘NHS Spine’, allowing them to access up-to-date information from patient records.
Alexander acknowledged that Curaleaf has now implemented this and believes it should be mandated for all private clinics. However, he agrees with the coroner’s conclusion that if the prescriber is aware that the patient is under the care of another psychiatrist, the “onus should be on them” to make contact and agree on a “shared care plan”.
3 – Once Curaleaf Clinic became aware that Oliver 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.
Curaleaf acknowledged that, with hindsight, it could have taken more proactive steps to establish direct communication with Oliver’s other treating psychiatrists, but disputed that responsibility lay solely with the clinic, stating that “communication is a two-way process.” It said it routinely shared clinic letters with Oliver’s GP and invited collaboration, and that the prescribing clinician asked Oliver to provide contact details for other psychiatrists, which he agreed but did not supply. The clinic also noted that Oliver himself contacted his NHS psychiatrist, copying Curaleaf, to request sharing of notes, which were not received, and accepted it could have followed up more assertively. Curaleaf added that both the Priory and NHS clinicians were aware of the prescription, yet no concerns were raised, and highlighted GMC guidance that patient safety concerns should be communicated.
Following its internal investigation, the clinic said it has introduced systems to better track and engage with external care teams, including requiring consent or non-objection from Community Mental Health Teams before prescribing.
(4) The continuation of prescriptions for medicinal cannabis acted as an obstacle to Oliver receiving appropriate psychiatric and addiction care.
Curaleaf disputes this characterisation and rejects the claim that its prescriptions acted as a barrier to appropriate care. Oliver remained under the care of his GP, the Priory, and NHS psychiatrists throughout, and that cannabis-based treatment did not ‘replace or prevent these engagements’.
The clinic pointed to improvements in Oliver’s self-reported depression scores—from severe to mild—as evidence of clinical benefit, while arguing that to characterise the prescription as ‘an obstacle’ to care, without giving equivalent weight to the well-documented psychosocial stressors identified at inquest, including financial difficulties, homelessness, loss of his driving licence, and relationship breakdown, ‘does not reflect the complexity of the case.’
It also noted issues around cost and periods of illicit cannabis use.
At the time of his treatment, Oliver is reported to have been spending around £1,000 per month on his prescription, substituting with illicit cannabis during periods when he could not afford the costs, which Alexander says “should have been a warning sign”.
Curaleaf says that it has since reviewed its approach to patients with complex psychiatric presentations and reinforced the importance of coordination with external mental health services.
