4 Feb 2026 Oliver Marc Robinson · Prevention of Future Deaths report Manchester North
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Concerns raised 5 Continuation of medicinal cannabis prescriptions obstructing appropriate psychiatric and addictions care View source Failure to exhaust available treatment options before prescribing medicinal cannabis View source Failure to base prescribing decisions on complete and current clinical information View source Lack of consultant-level expertise in treating adults with complex, treatment-resistant depression View source Failure to communicate directly with treating psychiatrists and obtain their views View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Reviewed the approach to patients with complex psychiatric presentations and reinforced coordination with relevant external mental health services through coordinated-care arrangements.
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Action
Required CMHT contact and explicit consent or non-objection before commencing CBMP treatment for patients receiving CMHT care.
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Action
Reinforced documentation of available clinical information and review of incomplete external information through MDT and clinical governance processes.
View source
Action
Implemented access to the NHS National Care Records Service to obtain contemporaneous clinical information for assessments and ongoing care.
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Action
Introduced electronic-record controls to identify external psychiatric or CMHT involvement, monitor engagement, and document relevant care coordination.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Curaleaf Clinic; that does not assign responsibility.
PFD Monitor interpretation Continuation of medicinal cannabis prescriptions obstructing appropriate psychiatric and addictions care
Wider context from the report “(4) The continuation of prescriptions for medicinal cannabis acted as an obstacle to Oliver receiving appropriate psychiatric and addictions care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Curaleaf Clinic; that does not assign responsibility.
PFD Monitor interpretation Failure to exhaust available treatment options before prescribing medicinal cannabis
Wider context from the report “(1) The Consultant Psychiatrist who reviewed Oliver at Cureleaf specialised in Child and Adolescent Psychiatry and had no Consultant level experience in treating adult patients with Oliver’s 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Curaleaf Clinic; that does not assign responsibility.
PFD Monitor interpretation Failure to base prescribing decisions on complete and current clinical information
Wider context from the report “(2) Cureleaf'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 . As such the prescribing decision was based on incomplete information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Curaleaf Clinic; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant-level expertise in treating adults with complex, treatment-resistant depression
Wider context from the report “(1) The Consultant Psychiatrist who reviewed Oliver at Cureleaf specialised in Child and Adolescent Psychiatry and had no Consultant level experience in treating adult patients with Oliver’s 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Curaleaf Clinic; that does not assign responsibility.
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 .
” Open source report
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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
Open published response
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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
Open published response
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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 Reinforced documentation of available clinical information and review of incomplete external information through MDT and clinical governance processes.
Verbatim wording from the response “Our internal investigation identified the reliance on SCRs as an area for improvement. The following changes were implemented prior to the inquest:” Source location Response from Curaleaf Clinic
Open published response
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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 Implemented access to the NHS National Care Records Service to obtain contemporaneous clinical information for assessments and ongoing care.
Verbatim wording from the response “Our internal investigation identified the reliance on SCRs as an area for improvement. The following changes were implemented prior to the inquest:” Source location Response from Curaleaf Clinic
Open published response
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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
Open published response
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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 The summary care record was less than a year old and contained information sufficient for the prescribing assessment.
Verbatim wording from the response “Coroner’s concern: 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. As such the prescribing decision was based on incomplete information.” Source location Response from Curaleaf Clinic
Open published response
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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
Open published response
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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 Treatment options were considered exhausted because multiple medication classes and extensive non-pharmacological treatments had already been tried.
Verbatim wording from the response “Exhaustion of Treatment Options” Source location Response from Curaleaf Clinic
Open published response
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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 The prescribing psychiatrist had substantial adult psychiatry training and experience despite specialising in child and adolescent psychiatry.
Verbatim wording from the response “We have engaged with this concern and respectfully disagree, for the reasons set out below.” Source location Response from Curaleaf Clinic
Open published response
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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 Continuing medicinal cannabis did not obstruct psychiatric or addictions care, which continued through the GP, Priory and NHS services.
Verbatim wording from the response “Coroner’s concern: The continuation of prescriptions for medicinal cannabis acted as an obstacle to Oliver receiving appropriate psychiatric and addictions care.” Source location Response from Curaleaf Clinic
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations