Cannabis concerns raised after man's fire death

The mental health of a man who died in a fire had deteriorated due to his use of medicinal cannabis, an inquest has heard.

Sixty-six-year-old David Morgan died in 2025 from breathing in smoke in his flat.

Presiding over the hearing, Deputy Viscount Matt Berry said Morgan's use of prescribed cannabis products contributed to his mental decline, and his mental state contributed to the circumstances of his death.

In a statement, the health minister said a consultation about cannabis prescribing would begin this month, ahead of creating a full licensing scheme. Berry recommended cannabis products were not prescribed to new patients with mental health conditions while this was under way.

The inquest heard Morgan's behaviour became "erratic" and "disorganised" in the weeks leading up to his death.

Evidence also suggested the fire started accidentally due to a heater placed too close to a sofa while Mr Morgan slept on 4 August 2025, it was told.

Morgan's family had raised concerns about his mental health.

As a result, police visited Morgan's flat days before he died. Officers assessed the mental health crisis team was not needed.

But, in his concluding statements, the coroner said there were "missed opportunities" for assessing Morgan directly.

Mental health service head Andy Weir previously told the inquest there lacked a collective response and he wanted there to be better multi-agency collaboration.

The coroner also said guidelines for prescribing cannabis were not followed.

Dr Steffen Osbelt prescribed the drug via Windsor Medical Practice following telephone consultations with Morgan.

Osbelt told the inquest this was "standard" practice, and gave him enough time to assess Morgan was suitable for the drug.

But Berry said Osbelt's assessments were largely based on Morgan's self-reports, going against health guidelines.

Morgan's GP, Dr Lisa Clynes, of 7 David Place Surgery, had raised concerns, and had been seeing Morgan since 2021 for long-term mental health issues.

She told the court he had been stable for a while, but in July 2025 she noticed "elated" and "euphoric" behaviour.

Clynes said it had also prompted him to stop taking other medications for anxiety.

She wrote a letter to the Windsor practice to state taking cannabis was "not in his best interest".

But the court heard two further prescriptions were issued following that letter.

Dr Osbelt said he was no longer the prescribing doctor by then but, if he had seen the letter, he would have stopped prescriptions "immediately".

Berry concluded Morgan died from "acute carbon monoxide poisoning resulting from exposure to fire, contributed to by starvation/stress-induced ketoacidosis and the consumption of unlicenced CBPMs [cannabis-based products for medicinal use]".

The conclusion also noted Morgan's "increasingly impulsive, disinhibited and erratic" behaviour and displays of psychotic symptoms that in the weeks before the fire.

"These symptoms contributed both to the circumstances of the ignition of the fire and to David's failure to escape from it," it said.

Berry added that "mental health services and the police, among others, were aware of David's symptoms, but opportunities for a direct mental health assessment in the days before David's death were missed".

In response, Health Minister Tom Binet said "action must be taken to ensure robust oversight and control of unlicensed medicinal cannabis prescribing in Jersey".

He added work was under way to introduce new legislation in early 2027 which would include a requirement for patients and doctors to meet face-to-face.

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