Prescribing medicinal cannabis - case study

03/10/2025

• Notification:

  • The Nursing and Midwifery Council of NSW (NMC) received a complaint from a member of the public regarding the way they obtained medicinal cannabis prescriptions and supply.

• Background:
  • The client accessed an online service and consulted with a nurse practitioner (NP) for what they reported was less than 10 minutes.

  • Following this consultation, they received several prescriptions for different types of medicinal cannabis. The client was advised to have each prescription filled and trial the products to determine which one suited them best.

• Assessment of risk:
  • No further information was provided regarding product details, including the delta-9-tetrahydrocannabinol (THC) strength, directions for use, potential side effects, or follow-up arrangements if issues arose.
  • All prescriptions were required to be filled through the same company, using its associated pharmacy service.
  • The products arrived by mail with no accompanying instructions.

  • The client trialled the various products, subsequently developed psychosis, and was admitted to hospital involuntarily. This was described as a highly distressing experience for both the client and their family.

• Risk:
  • The client alleged that the NP and the company failed to adhere to the standards of evidence-based practice, conduct a comprehensive health assessment, or develop a clear care plan. They also failed to provide advice about the product, including variations in THC strength, risks and benefits, side effects, and when or how to seek medical assistance if adverse effects occurred. The client believed the products were completely safe, natural, and harmless.
  • The NP did not respond when the client attempted to make contact after experiencing early psychotic symptoms.
  • The hospital treating team were unable to clearly establish the THC content of the medicinal cannabis used.
  • The client required several months to recover, reported distrust of health services, and experienced job loss and financial stress.
  • The impact on the client’s family remains unknown.

What the NMC did:

As the NMC only reviews the actions of the individual, we requested that the NP respond to the complaint by providing evidence of compliance with the Standards of Practice. This included demonstrating comprehensive health assessment, care planning, documentation, and evidence-based prescribing.

The NP was also asked to provide evidence of training, employment, and competency in the area of medicinal cannabis to demonstrate compliance with their scope of practice, as well as evidence of adherence to the TGA guidelines and the NSW Poisons and Therapeutic Goods Act in relation to prescribing.

 Concerns identified:

The NP was unable to demonstrate safe practice and had naively followed the scripts and advice provided by the company.

As a registered health practitioner, you ultimately hold the responsibility and accountability for your own practice, irrespective of your employer’s instructions.

Outcome:

The practitioner was referred by the notification committee to receive professional counselling and advice regarding obligations and responsibilities. The matter will remain on their file should further related matters be received.

Ahpra guidanceopen_in_new