Recurring concern

Failure to obtain and consider relevant treating psychiatrists' views

First to latest report 11 Feb 2021 — 4 Feb 2026

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 3

What this concern includes

Includes failures in patient-care processes to communicate directly with treating psychiatrists, seek their advice or views, and incorporate relevant information from psychiatrists who know the patient into assessment, prescribing or treatment decisions, including failures involving multiple psychiatric services and training or assessment arrangements that omit such views.

What is not included

Excludes generic clinical communication or information-sharing failures where relevant treating-psychiatrist input is not the material concern.
Excludes failures to obtain advice from non-psychiatric specialists unless the assertion explicitly concerns the same treating-psychiatrist consultation condition.
Excludes failures in the quality of a clinical decision where relevant treating-psychiatrist views were obtained and considered.
Excludes generic staff training or professional-curiosity deficiencies that are not specifically tied to obtaining or considering relevant treating psychiatrists' views.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Curaleaf Clinic1

West London NHS Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

4 Feb2026
Manchester North
Concerns raised1
1. Failure to communicate directly with treating psychiatrists and obtain their views
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Curaleaf Clinic
Stated actions 3
1. Curaleaf Clinic
  Introduced electronic-record controls to identify external psychiatric or CMHT involvement, monitor engagement, and document relevant care coordination.
2. Curaleaf Clinic
  Required CMHT contact and explicit consent or non-objection before commencing CBMP treatment for patients receiving CMHT care.
3. Curaleaf Clinic
  Reviewed the approach to patients with complex psychiatric presentations and reinforced coordination with relevant external mental health services through coordinated-care arrangements.
Respondent positions 1
1. Curaleaf Clinic
  Communication responsibility was not exclusively Curaleaf’s because other treating providers knew about the prescription and raised no concerns.
  Disputes the concern
AI-generated summary

Oliver Marc Robinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Oliver Robinson was 34 when his body was discovered at home on 24 November 2023. The Court found that he died by self-ligature tied during acute emotional dysregulation, in the context of multiple psychosocial stressors and cannabis dependence. The principal concerns were that Cureleaf prescribed medicinal cannabis despite incomplete information, insufficient relevant psychiatric expertise and treatment options not being exhausted, failed to liaise with treating psychiatrists, and that continued prescriptions obstructed appropriate psychiatric and addictions care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate directly with treating psychiatrists and obtain their views
Wider context from the report
“(3) Once Cureleaf 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. ”
Source location
Oliver Marc Robinson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduced electronic-record controls to identify external psychiatric or CMHT involvement, monitor engagement, and document relevant care coordination.

Verbatim wording from the response
“Internal Investigation Findings and Actions Taken”

Source location
Response from Curaleaf Clinic
Page 6 · response
Published 10 February 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Required CMHT contact and explicit consent or non-objection before commencing CBMP treatment for patients receiving CMHT care.

Verbatim wording from the response
“• For patients under Community Mental Health Team (CMHT) care, the clinic’s established process now requires that contact is made with the CMHT and that a decision to prescribe is not made until this has been confirmed.”

Source location
Response from Curaleaf Clinic
Page 5 · response
Published 10 February 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reviewed the approach to patients with complex psychiatric presentations and reinforced coordination with relevant external mental health services through coordinated-care arrangements.

Verbatim wording from the response
“Curaleaf Clinic has reflected carefully on the concerns raised in this case. The following changes have been implemented:”

Source location
Response from Curaleaf Clinic
Page 8 · response
Published 10 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communication responsibility was not exclusively Curaleaf’s because other treating providers knew about the prescription and raised no concerns.

Verbatim wording from the response
“We acknowledge that, with the benefit of hindsight, more proactive steps could have been taken by Curaleaf Clinic to establish direct communication with Mr Robinson’s other treating psychiatrists. However, the concern, as framed, attributes the communication failure exclusively to Curaleaf Clinic. Communication is a two-way process. Throughout Mr Robinson’s treatment, Curaleaf Clinic sent clinical letters to his GP after each consultation and expressly invited collaboration with other healthcare professionals. When Mr Robinson informed ████████ that another psychiatrist was involved in his care, she asked him to provide the relevant contact details. He agreed to do so but did not subsequently provide this information. Mr Robinson himself made efforts to facilitate communication between his healthcare providers.”

Source location
Response from Curaleaf Clinic
Page 6 · response
Published 10 February 2026
Open published response
11 Feb2021
Inner West London
Concerns raised1
1. Failure to train staff to consider the views of other qualified psychiatrists
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Valeria Munoz Biggs · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to train staff to consider the views of other qualified psychiatrists
Wider context from the report
“6. That the Trust staff should be trained to consider the views of other qualified psychiatrists with knowledge of a patient. ”
Source location
Valeria Munoz Biggs · Prevention of Future Deaths report
Page 3 · concerns
Open source report