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recurance

Oliver Robinson

4 Feb 2026 · Coroner Catherine McKenna · Manchester North

The coroner's concerns

  1. 1. inadequate adult psychiatric expertise

    “The Consultant [name redacted] who reviewed Oliverat Curaleaf specialised in Child and Adolescent Psychiatry and had no Consultant level experience in treating adult patients with [the deceased]'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. 2. incomplete information for prescribing

    “Curaleaf's initial prescribing decision was based on an out-of-date GP summary care record and without the knowledge that [the deceased] was under the care of a Consultant [name redacted] at the Priory. As such the prescribing decision was based on incomplete information.”
  3. 3. failure to coordinate with treating clinicians

    “Once Curaleaf Clinic became aware that [the deceased] had been reviewed by Consultant [name redacted] at the Priory and the NHS, it did not communicate directly with them or seek to inform themselves of the treating Psychiatrists' views.”
  4. 4. medicinal cannabis obstructing appropriate care

    “The continuation of prescriptions for medicinal cannabis acted as an obstacle to [the deceased] receiving appropriate psychiatric and addictions care.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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