Oliver Robinson

Curaleaf Clinic 
10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

17th February 2026 

Catherine McKenna 

Area Coroner for Manchester North 

HM Coroner’s Court 

Rochdale 

Re: Response to Regulation 28 Report to Prevent Future Deaths 

Deceased: Oliver Marc Robinson (born 13 July 1989, died 24 November 2023) 

Reference: 20260058 

Dear Ms McKenna, 

We write in response to the Regulation 28 Report to Prevent Future Deaths dated 4 February 

2026 concerning the death of Oliver Marc Robinson. This response is provided pursuant to 

Regulation 29 of the Coroners (Investigations) Regulations 2013. 

Curaleaf Clinic acknowledges the tragic circumstances of Mr Robinson’s death and extends 

its  deepest  sympathies  to  his  family.  Our  thoughts  remain  with  Mr  Robinson’s  family  and 

everyone affected by his death. 

We have engaged seriously with your concerns and, as detailed below, had already concluded 

a  comprehensive  internal  investigation  and  implemented  material  changes  to  our  clinical 

governance,  communication  processes,  and  ongoing  care  prior  to  the  commencement  of  the 

inquest.  The  findings  of  that  internal  investigation  and  the  changes  we  had  made  were 

available to the Court both by way of documentary and oral evidence.   

We note the conclusion in the Record of Inquest of death by misadventure, and the finding 

that Mr Robinson’s emotional dysregulation was caused by multiple factors and psychosocial 

stressors  including  conflicts  with  housing  and  NHS  services,  debt,  and  a  dependence  on 

cannabis obtained through both illicit sources and by prescription. We further note the Court’s 

finding that it is more likely than not that Mr Robinson did not intend the consequences of his 

actions. 

We respect the coronial process and the important role it serves. We note the concerns raised 

and address each below. 

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 Curaleaf Clinic 
10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

1. Qualifications of the Prescribing Consultant Psychiatrist and Exhaustion of Treatment 
Options 

Coroner’s concern: The Consultant Psychiatrist who reviewed Oliver at Curaleaf 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. 

We have engaged with this concern and respectfully disagree, for the reasons set out below. 

Scope of Practice 

 is a fully qualified Consultant Psychiatrist on the GMC Specialist Register 

), admitted to the Specialist Register for Child and Adolescent Psychiatry 

in  August  2020.  We  respectfully  submit  that  characterisation  of 

  as  having  “no 

Consultant level experience in treating adult patients” does not accurately reflect her training, 

qualifications, or clinical experience. 

All Consultant Psychiatrists in the United Kingdom are required to complete several years of 

training  in  adult  psychiatry  before  specialising. 

  worked  extensively  in  adult 

psychiatry  during  her  training  and  subsequently  was  employed  as  a  Staff  Grade  doctor  in 

adult psychiatry for three years, including two years in an adult crisis team after receiving her 

Certificate of Completion of Training. She also worked for five years in inpatient psychiatry 

and, during on-call duties, covered the entire hospital including adult patients. She is a Section 

12(2) approved doctor, defined as a registered medical practitioner with special expertise in 

diagnosing or treating mental disorders, approved by the Secretary of State under the Mental 

Health Act 1983. She continues to undertake Mental Health Act assessments for adult patients 

in her role as a consultant psychiatrist. 

 has been employed by Curaleaf Clinic since April 2021 and is one of the clinic’s 

most  experienced  consultant  psychiatrists.  Prior  to  this  case,  there  had  been  no  formal 

complaints,  serious  incidents,  or  adverse  events  recorded  in  relation  to  patients  under  her 

care. 

Critically, Mr Robinson’s case was not managed by 

 in isolation. Curaleaf Clinic 

operates a formal multidisciplinary team (MDT) process through which every patient must 

be reviewed before a prescribing decision is made. No individual clinician may unilaterally 

initiate  treatment  with  cannabis-based  medicinal  products  (CBMPs).  The  MDT  requires  a 

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10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

quorum comprising consultants from different medical specialities with experience in medical 

cannabis  therapy,  an  advanced  specialist  pharmacist  certified  for  independent  prescribing, 

and the clinic’s operations or medical director. The proceedings are formally minuted by the 

operations team. 

Following the initial consultation, Mr Robinson’s suitability for treatment was reviewed and 

approved at an MDT meeting on 5 May 2022. The MDT comprised of 

, another 

consultant psychiatrist (adult), a consultant medical physician, a consultant in palliative care, 

a consultant anaesthetist, and a specialist pharmacist certified for independent prescribing. 

The prescribing decision was a collective clinical decision made with the input of additional 

clinicians, not a unilateral decision by 

. 

Exhaustion of Treatment Options 

We dispute the assertion that treatment options had not been exhausted at the time CBMPs 

were  prescribed.  Mr  Robinson  had  trialled  the  following  medications:  escitalopram, 

duloxetine, venlafaxine, reboxetine, mirtazapine, quetiapine, and aripiprazole. He also had a 

documented severe adverse reaction to amitriptyline. This represents treatment with all major 

classes  of  antidepressant  medication,  including  selective  serotonin  reuptake  inhibitors 

(SSRIs),  serotonin–norepinephrine  reuptake  inhibitors  (SNRIs),  tetracyclic  antidepressants, 

tricyclic antidepressants (TCAs), and antipsychotics for mood augmentation. 

In addition, Mr Robinson had undergone extensive non-pharmacological treatments: referral 

to Improving Access to Psychological Therapies (IAPT), a one-month inpatient admission to 

the  Priory  Hospital  Altrincham  and  associated  therapies,  outpatient  cognitive  behavioural 

therapy (CBT), advanced CBT group therapy, over 60 sessions of schema therapy, and eye 

movement  desensitisation  and  reprocessing  (EMDR).  Despite  this  extensive  treatment 

history, Mr Robinson continued to experience significant symptoms. 

The  remaining  licensed  pharmacological  options  —  principally  lithium  and  monoamine 

oxidase  inhibitors  —  both  carry  substantial  safety  risks  in  themselves.  Importantly,  Mr 

Robinson did not wish to take these medications. A treatment that a patient refuses cannot be 

considered  a  viable  therapeutic  option.  There  were  also  pre-existing  difficulties  with 

medication  compliance  documented  in  his  records,  making  the  prescription  of  higher-risk 

medications a less appropriate course of action. 

The  regulatory  framework  under  which  CBMPs  are  prescribed  requires  that  licensed 

treatments have been trialled and have not provided satisfactory improvement or have caused 

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10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

side effects leading to poor adherence or discontinuation. That threshold was clearly met. The 

MHRA guidance does not require that every possible licensed treatment has been exhausted 

before CBMPs can be prescribed. 

Mr  Robinson  was  an  adult  with  capacity  who,  after  informed  consent,  chose  to  pursue  a 

consultation to assess whether CBMPs could manage his symptoms. He self-referred to the 

clinic. As part of the consent process, Mr Robinson signed a treatment agreement which set 

out the responsibilities of both patient and clinician, including transparency about potential 

side effects, the requirement to inform the clinician of any concurrent substance use, and an 

undertaking to abstain from illicit cannabis. It is important to contextualise this: Mr Robinson 

had been using illicit cannabis prior to attending the clinic, which carries materially different 

risks from prescribed, pharmaceutical-grade CBMPs administered under clinical supervision 

in  controlled  dosages.  The  treatment  agreement  was  designed  to  transition  him  from 

unregulated use to monitored, clinically directed treatment. 

Clinical  outcome  measures  demonstrated  significant  improvement  during  treatment.  Mr 

Robinson’s patient-reported outcome measures, collected through the UK Medical Cannabis 

Registry, showed that his Patient Health Questionnaire-9 depression score fell from 23 (severe 

depression) at baseline to 8 (mild depression) at his last assessment. This 15-point reduction 

exceeds the five-point threshold for a clinically significant improvement. 

2. Reliance on an Out-of-Date GP Summary Care Record and Incomplete Information 

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. 

The Summary Care Record (SCR) was less than a year old when reviewed by the MDT, and 

we do not accept that this resulted in a materially flawed prescribing decision. 

The SCR that was available contained the clinical information necessary for the assessment of 

Mr Robinson’s eligibility for CBMPs: namely, his objective diagnosis of depression and the 

record  of  licensed  medications  that  had  been  trialled  without  sustained  benefit.  The 

prescribing clinician also took a detailed clinical history directly from Mr Robinson, who had 

capacity,  and 

  specifically  asked  about  any  changes  or  updates  to  his  care  or 

medications. It is important to note that the SCR is a nationally managed record produced by 

NHS  systems.  Its  currency  depends  on  when  information  is  uploaded  by  the  patient’s  GP 

practice.  Private  healthcare  providers,  including  Curaleaf  Clinic,  do  not  control  how 

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frequently SCRs are updated. To characterise the prescribing decision as having been based 

on  “incomplete  information”,  without  acknowledging  the  inherent  limitations  of  the  SCR 

system, presents an incomplete picture. 

The  Priory  was  aware  that  Mr  Robinson  was  prescribed  CBMPs,  as  he  had  informed  his 

consultant psychiatrist of this. No communication was received by Curaleaf Clinic from the 

Priory, nor did the Priory contact the clinic to raise any concerns about the prescription. 

Throughout  Mr  Robinson’s  treatment  at  the  clinic  the  decision  to  prescribe  and  the 

medications he was prescribed was communicated to his GP via formal electronic letters, as 

is standard practice. The GP was aware of this and wrote a letter detailing their knowledge of 

his prescription. 

Despite other parties being aware of Mr Robinson’s prescription for CBMPs, Curaleaf Clinic 

was not contacted by these other agencies to raise concerns if those concerns were present at 

the time.  

Once Curaleaf Clinic became aware of the involvement of other psychiatrists in Mr Robinson’s 

care,  efforts  were  made  to  contact  them  to  corroborate  the  information  provided  by  Mr 

Robinson. 

Internal Investigation Findings and Actions Taken 

Our internal investigation identified the reliance on SCRs as an area for improvement. The 

following changes were implemented prior to the inquest: 

•  Curaleaf  Clinic  was  amongst  the  first  specialised  medical  cannabis  clinics  to 

implement access to the NHS National Care Records Service (NCRS / Spine), enabling 

clinicians  to  obtain  contemporaneous  clinical  information  directly  to  support  both 

initial assessments and ongoing care. 

•  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. 

•  The  clinic  has  reinforced  the  importance  of  documenting  the  clinical  information 

available  at  the  point  of  decision-making,  with  cases  involving  incomplete  external 

information  considered  through  MDT  discussion  and  wider  clinical  governance 

processes. 

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10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

3. Communication with Treating Psychiatrists 

Coroner’s concern: Once Curaleaf 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. 

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  routinely  sent  clinic  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. On 14 July 2023, he sent an email to his NHS psychiatrist, 

copying Curaleaf Clinic, requesting that his clinic notes be shared. Curaleaf acknowledged 

this communication and awaited the notes, but they were not received. On reflection Curaleaf 

Clinic  could  have  taken  a  more  proactive  approach  by  initiating  contact  with  the  NHS 

psychiatrist following the non-response to this communication. 

We  respectfully  observe  that  a  finding  of  communication  failure  has  only  been  directed  at 

Curaleaf Clinic. As highlighted by way of documentary and oral evidence heard by the Court, 

the Priory and Mr Robinson's NHS psychiatrist were aware that Mr Robinson was prescribed 

CBMPs, as he had informed them of this.  

The  GMC  provides  guidance  that  all  medical  professionals  have  a  duty  to  raise  concerns 

where  they  believe  that  patient  safety  or  care  is  being  compromised  by  the  practice  of 

colleagues or systems, policies and procedures. As highlighted, no commmunications were 

received from any outside party during the time Mr Robinson was treated by Curaleaf Clinic 

to indicate they had any concerns about his prescription. 

Internal Investigation Findings and Actions Taken 

Our  internal  investigation  identified  that  opportunities  to  establish  direct  communication 

with third-party psychiatrists were missed. The following changes were implemented prior 

to the inquest: 

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10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

•  System changes have been introduced to the clinic’s electronic health record to record 

and  monitor  whether  a  patient  is  under  CMHT  care  or  the  care  of  an  external 

psychiatrist, and to log engagement with those services. 

•  For patients under CMHT care, explicit consent or non-objection from the CMHT is 

now obtained before commencing treatment with CBMPs. 

•  These processes have been incorporated into the clinic’s regular audit cycle and form 

part of the high-risk patient pathway. 

4. Whether the Continuation of Medicinal Cannabis Acted as an Obstacle to Appropriate 
Psychiatric and Addictions Care 

Coroner’s concern: The continuation of prescriptions for medicinal cannabis acted as an obstacle to 

Oliver receiving appropriate psychiatric and addictions care. 

We have reflected on the highlight concern and dispute this characterisation.  

Psychiatric Care 

Throughout the period of his treatment with CBMPs, Mr Robinson remained under the care 

of his GP, who continued to prescribe his conventional psychiatric medications. He was also 

seen by psychiatrists at the Priory and by the NHS. The CBMP prescription did not displace 

or prevent any of these engagements.  

Mr  Robinson’s  patient-reported  outcome  measures  provide  objective  evidence  that  his 

condition  improved  during  treatment  with  CBMPs.  His  Patient  Health  Questionnaire-9 

depression  score  fell  from  23  (severe  depression)  at  baseline  at  the  commencement  of 

treatment to 8 (mild depression) by July 2023 — a clinically significant improvement.  

The Record of Inquest recognises that Mr Robinson’s emotional dysregulation was caused by 

multiple factors and psychosocial stressors. The evidence heard at inquest included financial 

difficulties,  homelessness,  loss  of  his  driving  licence,  relationship  breakdown,  and  conflict 

with both NHS services and housing services. To characterise the CBMP prescription as “an 

obstacle” to care, without giving equivalent weight to these well-documented psychosocial 

factors, does not reflect the complexity of the case. 

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 Curaleaf Clinic 
10 Harley Street  
London, W1G 9PF 

www.curaleafclinic.com 

Internal Investigation Findings and Actions Taken 

Curaleaf  Clinic  has  reflected  carefully  on  the  concerns  raised  in  this  case.  The  following 

changes have been implemented: 

•  The  clinic  has  reviewed  its  approach  to  patients  with  complex  psychiatric 
presentations  and  reinforced  the  importance  of  coordination  with  external  mental 

health services, including CMHTs, where applicable. 

•  Where a patient is receiving care from a CMHT or other relevant services, the clinic 

seeks to support coordinated care by communicating with those services (with patient 

consent) and ensuring that CBMP treatment proceeds only where appropriate ongoing 

care arrangements are in place. 

•  These  considerations  are  addressed  through  MDT  discussion  and  the  clinic’s 

established clinical governance framework. 

Conclusion 

Curaleaf Clinic has reflected carefully on the circumstances of this case. As set out above, we 

had  already  identified  –  and  provided  evidence  about  –  the  key  areas  for  improvement 

through our own internal investigation and had implemented material changes to our clinical 

governance, communication, and shared-care processes before the inquest commenced. 

We  remain  committed  to  continuous  improvement,  robust  clinical  governance,  and 

constructive engagement with coronial and regulatory processes. Our priority is, and always 

has  been,  the  delivery  of  responsible,  clinically  led  care  within  established  medical  and 

regulatory frameworks, with the aim of ensuring the safety of all our patients. 

We trust that this response addresses the matters raised in the Regulation 28 report.  

Our thoughts and sincerest sympathies remain with Mr Robinson’s family and loved ones at 

this time. 

Yours sincerely, 

Curaleaf Clinic 

10 Harley Street, London, W1G 9QY 

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