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Inquest highlights concerns over medicinal cannabis after fatal Jersey flat fire
Overview
An inquest has found that the mental health decline of 66-year-old David Morgan, exacerbated by prescribed medicinal cannabis, contributed to the circumstances of his death in an accidental flat fire in St Helier in August 2025. Deputy Viscount Matt Berry noted that guidelines for prescribing cannabis were not followed, assessments relied heavily on self-reporting, and missed opportunities occurred for direct mental health assessments by services in the days leading up to the fire.
Key points
- David Morgan died in August 2025 from acute carbon monoxide poisoning after an accidental fire started by a heater placed too close to a sofa.
- The inquest concluded that Morgan's use of unlicensed cannabis-based products for medicinal use contributed to his mental decline and erratic behaviour.
- Coroner Matt Berry stated that prescribing guidelines were not followed and that assessments by Dr Steffen Osbelt relied largely on patient self-reports.
- Morgan's GP had raised concerns that cannabis was not in his best interest, but subsequent prescriptions were still issued.
- The coroner highlighted missed opportunities by mental health services and police to assess Morgan directly in the days before his death.
- Jersey's Health Minister announced plans for a consultation on cannabis prescribing and new legislation requiring face-to-face meetings between patients and doctors.