--- title: "Jersey inquest finds missed chances before cannabis-linked fire death" url: https://www.nsfw.info/jersey-inquest-cannabis-linked-fire-death-missed-chances/ published: 2026-10-14T09:00:50+00:00 modified: 2026-10-14T09:00:50+00:00 author: "Chief Editor" categories: ["News"] image: https://www.nsfw.info/wp-content/uploads/2026/10/jersey-inquest-cannabis-linked-fire-death-missed-chances-1024x572.webp summary: "A Jersey inquest found medicinal cannabis contributed to David Morgan's mental decline before he died in a flat fire, with prescribing guidelines ignored and me" publisher: NSFW (https://www.nsfw.info) --- # Jersey inquest finds missed chances before cannabis-linked fire death **In brief:** A Jersey inquest has concluded that medicinal cannabis contributed to the mental decline of David Morgan, 66, who died in a flat fire in August 2025. The Deputy Viscount found that prescribing guidelines were not followed and that mental health services missed opportunities to assess Morgan directly. Jersey’s Health Minister has since announced a consultation on cannabis prescribing and pledged new legislation by early 2027. ## A Death in Disputed Circumstances David Morgan, aged 66, died on 4 August 2025 after breathing in smoke in his flat. The BBC reports that the inquest heard evidence suggesting the fire started accidentally when a heater was placed too close to a sofa while Morgan slept. The Deputy Viscount, Matt Berry, concluded that Morgan died from “acute carbon monoxide poisoning resulting from exposure to fire, contributed to by starvation/stress-induced ketoacidosis and the consumption of unlicensed cannabis-based products for medicinal use.” In the weeks before his death, Morgan’s behaviour had become, in the words of the inquest, “erratic” and “disorganised.” Berry’s conclusion noted that Morgan’s “increasingly impulsive, disinhibited and erratic” behaviour, along with displays of psychotic symptoms, “contributed both to the circumstances of the ignition of the fire and to David’s failure to escape from it.” ## Prescribing Guidelines Ignored, GP’s Warning Overlooked At the heart of the inquest was the question of how Morgan came to be prescribed cannabis in the first place, and why those prescriptions continued despite clear warning signs. Dr Steffen Osbelt prescribed the drug via Windsor Medical Practice following telephone consultations with Morgan, telling the inquest this was “standard” practice and gave him sufficient time to assess Morgan’s suitability. Berry disagreed, finding that Osbelt’s assessments were largely based on Morgan’s own self-reports, going against health guidelines. Morgan’s GP, Dr Lisa Clynes of 7 David Place Surgery, had been seeing him since 2021 for long-term mental health issues. She told the court he had been stable for a period, but that by July 2025 she noticed “elated” and “euphoric” behaviour, and that the cannabis use had prompted him to stop taking other medications for anxiety. She wrote a letter to the Windsor practice stating that taking cannabis was “not in his best interest.” Despite this, the court heard that two further prescriptions were issued after that letter was sent. Dr Osbelt said he was no longer the prescribing doctor by that point, but told the inquest that had he seen the letter, he would have stopped prescriptions “immediately.” ## Missed Opportunities and a Fragmented Response Morgan’s family had raised concerns about his mental health before his death. Police visited his flat in the days prior, but officers assessed that the mental health crisis team was not needed. Berry concluded there were “missed opportunities” for assessing Morgan directly, and that “mental health services and the police, among others, were aware of David’s symptoms” without acting decisively. Andy Weir, head of mental health services, previously told the inquest that there had been a lack of collective response and that he wanted to see better multi-agency collaboration in future. It is a familiar refrain in tragedies of this kind, and one that rarely seems to translate quickly into practice. ## Government Response and the Road to Regulation Health Minister Tom Binet said in a statement that “action must be taken to ensure robust oversight and control of unlicensed medicinal cannabis prescribing in Jersey.” He confirmed that a consultation on cannabis prescribing would begin this month, ahead of creating a full licensing scheme. Work is also under way to introduce new legislation in early 2027, which would include a requirement for patients and doctors to meet face-to-face. In the meantime, Berry recommended that cannabis products should not be prescribed to new patients with mental health conditions while the consultation is ongoing. ## The NSFW Perspective There is something deeply troubling about a system in which a GP writes a letter saying a prescription is “not in her patient’s best interest,” two more prescriptions are issued anyway, and the patient subsequently dies. Whatever one thinks about medicinal cannabis in principle, the case of David Morgan illustrates what happens when a new and loosely regulated treatment is introduced without the safeguards that any reasonable person would expect. Telephone consultations, self-reported assessments and a near-total absence of joined-up thinking between prescribers, GPs and mental health services: it is not a picture that inspires confidence. The Health Minister’s promise of legislation by early 2027 is welcome, but one might reasonably ask why robust face-to-face requirements and proper oversight were not built in from the start. Jersey is a small island with a close-knit medical community. The excuse that nobody knew what was happening does not sit easily with the facts as presented to the inquest. A family has lost a father and a husband. The least the system owes them is a genuine reckoning with how it failed him. *Source: [BBC News](https://www.bbc.co.uk/news/articles/cwy7l0exjzyeo)*