Oliver Marc Robinson · Prevention of Future Deaths report

On 29 November 2023 an investigation into the death of Oliver Marc Robinson was commenced. The investigation concluded at the end of the inquest on 30 January 2026, I recorded a conclusion of Misadventure.

Oliver Robinson was 34 years old when his body was discovered at his home address on 24 November 2023. He died by means of self-ligature which he had tied at a time when he was experiencing acute emotional dysregulation. The Court found that his actions in tying the ligature were undertaken as a means of communicating distress rather than with an intention to end his life.

The Court also found that Oliver’s emotional dysregulation was caused by multiple factors and psychosocial stressors including conflicts with housing and NHS services, debt and a physical and psychological dependence on cannabis which he was obtaining through illicit sources and by way of a prescription from a private clinic.

Oliver had enrolled on the UK Medical Cannabis Registry research study run by Cureleaf Clinic in April 2022 and received prescriptions for medicinal cannabis for the treatment of treatment-resistant depression between 7 May 2022 and 17 November 2023. During this time, there were periods when he could not afford to pay for the prescription of medicinal cannabis and would use illicit cannabis as a substitute.

Oliver had a background history of addictive tendencies which included excessive cannabis use. He had been under the care of a Consultant Psychiatrist at the Priory Clinic between September 2019 and September 2022 who had diagnosed him with depression but was of the view that by January/February 2022 Oliver’s addictive behaviours were the larger problem impacting on his mood. Oliver declined the addictions programme that was offered by the Psychiatrist at that time. Following an assessment by an NHS Consultant Psychiatrist in April 2023, Oliver was given a dual diagnosis of Recurrent Depressive Disorder and Mental and Behavioural Disorder due to Cannabinoid Dependence. Notwithstanding this context, Cureleaf clinic continued to issue prescriptions for medicinal cannabis to Oliver.

(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.
(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.
(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.
(4) The continuation of prescriptions for medicinal cannabis acted as an obstacle to Oliver receiving appropriate psychiatric and addictions care.