For the first time, a coroner has found that a medical cannabis prescription contributed to a death.

A Landmark Ruling

In January 2026, following a full inquest at Rochdale Coroners' Court, Area Coroner Catherine McKenna ruled that the prescription of medical cannabis by Curaleaf Clinic contributed to Oliver Robinson's death. 

What the coroner found: 

The prescription of medical cannabis: 

  • Reinforced Oliver's belief that cannabis was essential for treating his depression

  • Legitimised his cannabis use despite clinical evidence it worsened his conditions

  • Maintained and enabled a pre-existing dependency on cannabis 

  • Created barriers to advice from his NHS & Priory psychiatrists 

  • Contributed to emotional dysregulation, worsening mental state, and was part of the causal chain leading to his death 

What went wrong:

  • The coroner found that Curaleaf Clinic and Dr. Urmila Bhoskar prescribed medical cannabis based on incomplete clinical information: 

  • No contact with Oliver's treating NHS psychiatrist, Dr Nadeem or previous Priory psychiatrist, Dr. Haslam 

  • A single video consultation as the basis for prescribing

  • GP records reviewed prior to issuing the prescription were 9 months out of date. 

  • Failure to properly assess Oliver's documented psychiatric conditions including cannabis dependency 

  • Prescribing by a child psychiatrist to an adult patient 

What the experts said: 

Psychiatrist Dr. Pavan Chahl told the inquest: 

"Under current British National Formulary guidance, medicinal cannabis should not be prescribed to someone with a history of severe psychiatric disorder. There is a lack of evidence for efficacy in depression, and evidence it can cause or worsen depression. On this evidence, Oliver Robinson should never have been prescribed medicinal cannabis." 

Dr. Richard Haslam, Oliver's NHS psychiatrist, stated he would have urged the prescriber not to prescribe cannabis had he been contacted. 

The coroner's action: 

Coroner Catherine McKenna has: 

  • Issued a Prevention of Future Deaths (Regulation 28) report to Curaleaf Clinic, requiring them to explain what action they will take to prevent similar deaths 

  • Referred the prescribing doctor to the General Medical Council for investigation 

The inquest highlighted gaps in how private cannabis prescribing is overseen and coordinated with NHS care. Addressing those gaps is essential for patient safety.

Read the report