The inquest into the death of Oliver Robinson, a patient with complex mental health issues who was being prescribed medical cannabis at the time of his death, resulted in a Prevention of Future Deaths report (PFD) being issued this year to Curaleaf Clinic (Curaleaf) (the report can be accessed here: Oliver Robinson: Prevention of future deaths report). Mr Robinson's death is a tragedy, and the inquest proceedings have prompted serious reflection across the sector.
In this blog, we analyse what the PFD, and Curaleaf's response to it, mean in practice for clinics prescribing Cannabis-Based Products for Medicinal Use (CBPMs).
PFD reports are not just relevant to the organisation named in them. They can represent a coroner's formal assessment of systemic risk. Any clinic prescribing CBPMs to patients with mental health conditions should treat the concerns raised in the PFD as a direct prompt to review its own processes.
1. Clinician experience, decision-making procedures, and record-keeping
The Coroner concluded that the Consultant Psychiatrist who reviewed Mr Robinson at Curaleaf did not have appropriate experience to treat adult patients with a complex presentation, and that treatment options other than medical cannabis had not been exhausted.
In response, Curaleaf submitted that Mr Robinson's treatment had been reviewed and approved by a multidisciplinary team (MDT), including a specialist pharmacist, and was a "collective clinical decision… not a unilateral decision". Additionally, Mr Robinson had undergone numerous treatments (both pharmacological and non-pharmacological) without improvement, had refused other treatments and had showed clinically significant improvement during his treatment with medical cannabis.
Reflection: Notwithstanding Curaleaf's defence of its processes, the Coroner's concerns highlight the importance of clinics keeping clear records of a patient's treatment and having processes in place to ensure prescribing decisions are made in line with relevant guidance. For example, NHS England guidance advises that "decisions… should be based on a multidisciplinary team discussion" when prescribing CBPMs.
Where a single clinician makes a prescribing decision without MDT input, the clinic's exposure in any future inquest is likely to be materially greater. Equally, a clear written record that other treatment options have been considered and, where relevant, declined by the patient is essential. A well-maintained clinical record can be a clinic's most important protection.
2. Availability of complete clinical information
The Coroner was concerned that the initial prescribing decision was based on an out of date GP summary care record (SCR) and without knowledge that Mr Robinson was also under the care of a psychiatrist at the Priory (an independent mental healthcare provider).
Curaleaf's position was that the SCR used was sufficiently up to date and contained the key details required for an assessment of eligibility for CBPMs. Additionally, once it became aware of the Priory psychiatrist's involvement, it took steps to contact them to corroborate information.
Curaleaf also outlined steps it had taken to mitigate any shortcomings in respect of its reliance on SCRs, following an internal investigation it had undertaken in response to Mr Robinson's death in advance of the inquest proceedings. Curaleaf has implemented access to the NHS National Care Records Service to obtain up to date clinical information on patients. It has also amended its processes so that, at the point of decision-making, incomplete external information is considered through MDT discussion.
Reflection: Clinics should carefully review their own reliance on SCRs and take proactive steps to ensure they have a complete understanding of all healthcare providers involved in a patient's care. As this case illustrates, clinics can face criticism if a coroner considers that a prescribing decision was made based on incomplete information.
3. Proactive engagement with other healthcare providers
The Coroner found that Curaleaf had not communicated directly with psychiatrists at the Priory or the NHS once aware that they had assessed Mr Robinson.
Although Curaleaf accepted that it could have taken more proactive steps to contact Mr Robinson's other psychiatrists, it also maintained that communication is a shared responsibility, and that other clinicians who had a professional duty to raise any patient safety concerns did not do so.
Curaleaf's internal investigation prompted by Mr Robinson's case concluded that opportunities to "establish direct communication with third-party psychiatrists were missed", which led to the implementation of a number of changes in the clinic's systems. For example, explicit consent/non-objection is now sought before commencing treatment with CBPMs for patients receiving Community Mental Health Team (NHS) care.
Reflection: Clinics should consider implementing a similar pre-condition of consent/non-objection before CBPM treatment can commence. Doing so will help ensure that any third-party psychiatrist's views are obtained by the prescribing clinic.
4. CBPM prescribing embedded within a wider treatment pathway
The Coroner expressed concern that the continued prescribing of medical cannabis acted as an obstacle to Mr Robinson receiving appropriate psychiatric and addictions care.
Curaleaf disagreed, stating that Mr Robinson remained under the care of his GP and other psychiatrists throughout his treatment at Curaleaf, and that the medical cannabis he was prescribed did not replace or disrupt that care. Additionally, the clinic referred to how Mr Robinson's depression had improved as a result of his medical cannabis prescription and noted that his death was caused by "multiple factors and psychosocial stressors", which meant that the Coroner's finding that his medical cannabis prescription was an "obstacle" did "not reflect the complexity of the case".
Reflection: CBPM clinics should ensure that cannabis prescribing is clearly embedded within a wider, actively managed treatment pathway, with robust coordination and information-sharing between a patient's GP and other third-party healthcare providers. CBPM treatment should be kept under continuous review in respect of how it may impact a patient's engagement with psychiatric and addictions care, to ensure it supports access and does not act as an "obstacle", as was found in this case.
CBPM-prescribing clinics should take proactive steps to ensure that prescribing decisions are underpinned by complete clinical information, meaningful multidisciplinary oversight and effective engagement with other healthcare providers involved in a patient's treatment. Even where care is clinically justified, the ability to evidence robust processes and clear lines of communication may be critical in withstanding scrutiny.
In this blog, we analyse what the PFD, and Curaleaf's response to it, mean in practice for clinics prescribing Cannabis-Based Products for Medicinal Use (CBPMs).
The significance of a PFD addressed to Curaleaf
The issuing of a PFD to Curaleaf following the inquest means that, during the investigation, the Coroner identified a risk of future deaths arising from the same circumstances and that, in her view, Curaleaf is in a position to eliminate or reduce that risk.PFD reports are not just relevant to the organisation named in them. They can represent a coroner's formal assessment of systemic risk. Any clinic prescribing CBPMs to patients with mental health conditions should treat the concerns raised in the PFD as a direct prompt to review its own processes.
Our reflections on the PFD
The PFD outlined four key concerns relating to whether Curaleaf's prescribing practices are adequate to prevent future deaths.1. Clinician experience, decision-making procedures, and record-keeping
The Coroner concluded that the Consultant Psychiatrist who reviewed Mr Robinson at Curaleaf did not have appropriate experience to treat adult patients with a complex presentation, and that treatment options other than medical cannabis had not been exhausted.
In response, Curaleaf submitted that Mr Robinson's treatment had been reviewed and approved by a multidisciplinary team (MDT), including a specialist pharmacist, and was a "collective clinical decision… not a unilateral decision". Additionally, Mr Robinson had undergone numerous treatments (both pharmacological and non-pharmacological) without improvement, had refused other treatments and had showed clinically significant improvement during his treatment with medical cannabis.
Reflection: Notwithstanding Curaleaf's defence of its processes, the Coroner's concerns highlight the importance of clinics keeping clear records of a patient's treatment and having processes in place to ensure prescribing decisions are made in line with relevant guidance. For example, NHS England guidance advises that "decisions… should be based on a multidisciplinary team discussion" when prescribing CBPMs.
Where a single clinician makes a prescribing decision without MDT input, the clinic's exposure in any future inquest is likely to be materially greater. Equally, a clear written record that other treatment options have been considered and, where relevant, declined by the patient is essential. A well-maintained clinical record can be a clinic's most important protection.
2. Availability of complete clinical information
The Coroner was concerned that the initial prescribing decision was based on an out of date GP summary care record (SCR) and without knowledge that Mr Robinson was also under the care of a psychiatrist at the Priory (an independent mental healthcare provider).
Curaleaf's position was that the SCR used was sufficiently up to date and contained the key details required for an assessment of eligibility for CBPMs. Additionally, once it became aware of the Priory psychiatrist's involvement, it took steps to contact them to corroborate information.
Curaleaf also outlined steps it had taken to mitigate any shortcomings in respect of its reliance on SCRs, following an internal investigation it had undertaken in response to Mr Robinson's death in advance of the inquest proceedings. Curaleaf has implemented access to the NHS National Care Records Service to obtain up to date clinical information on patients. It has also amended its processes so that, at the point of decision-making, incomplete external information is considered through MDT discussion.
Reflection: Clinics should carefully review their own reliance on SCRs and take proactive steps to ensure they have a complete understanding of all healthcare providers involved in a patient's care. As this case illustrates, clinics can face criticism if a coroner considers that a prescribing decision was made based on incomplete information.
3. Proactive engagement with other healthcare providers
The Coroner found that Curaleaf had not communicated directly with psychiatrists at the Priory or the NHS once aware that they had assessed Mr Robinson.
Although Curaleaf accepted that it could have taken more proactive steps to contact Mr Robinson's other psychiatrists, it also maintained that communication is a shared responsibility, and that other clinicians who had a professional duty to raise any patient safety concerns did not do so.
Curaleaf's internal investigation prompted by Mr Robinson's case concluded that opportunities to "establish direct communication with third-party psychiatrists were missed", which led to the implementation of a number of changes in the clinic's systems. For example, explicit consent/non-objection is now sought before commencing treatment with CBPMs for patients receiving Community Mental Health Team (NHS) care.
Reflection: Clinics should consider implementing a similar pre-condition of consent/non-objection before CBPM treatment can commence. Doing so will help ensure that any third-party psychiatrist's views are obtained by the prescribing clinic.
4. CBPM prescribing embedded within a wider treatment pathway
The Coroner expressed concern that the continued prescribing of medical cannabis acted as an obstacle to Mr Robinson receiving appropriate psychiatric and addictions care.
Curaleaf disagreed, stating that Mr Robinson remained under the care of his GP and other psychiatrists throughout his treatment at Curaleaf, and that the medical cannabis he was prescribed did not replace or disrupt that care. Additionally, the clinic referred to how Mr Robinson's depression had improved as a result of his medical cannabis prescription and noted that his death was caused by "multiple factors and psychosocial stressors", which meant that the Coroner's finding that his medical cannabis prescription was an "obstacle" did "not reflect the complexity of the case".
Reflection: CBPM clinics should ensure that cannabis prescribing is clearly embedded within a wider, actively managed treatment pathway, with robust coordination and information-sharing between a patient's GP and other third-party healthcare providers. CBPM treatment should be kept under continuous review in respect of how it may impact a patient's engagement with psychiatric and addictions care, to ensure it supports access and does not act as an "obstacle", as was found in this case.
Final comments
This case is a reminder that, whether or not clinical decisions are well-intentioned and therapeutically justified, a coroner's inquest will subject them to searching retrospective scrutiny. While Curaleaf's response robustly defended its clinicians, decision-making processes and the therapeutic benefit observed in Mr Robinson's treatment, it also demonstrated a willingness to reflect critically on aspects of its systems and to implement changes as a result.CBPM-prescribing clinics should take proactive steps to ensure that prescribing decisions are underpinned by complete clinical information, meaningful multidisciplinary oversight and effective engagement with other healthcare providers involved in a patient's treatment. Even where care is clinically justified, the ability to evidence robust processes and clear lines of communication may be critical in withstanding scrutiny.
