Tasmanian coroner finds doctor's irresponsible prescribing linked to two deaths
Consensus Summary
A Tasmanian coroner found that Dr David Jackson's 'grossly irresponsible prescribing' of methadone and benzodiazepines directly caused the deaths of two patients, Nicholas Brown (35) and Matthew Winwood (47), between September 2016 and August 2017. The coroner, Olivia McTaggart, determined Jackson's actions were negligent and contrary to clinical guidelines, despite a criminal investigation resulting in no charges. Jackson had a long history of concerns about his prescribing practices, dating back to the early 1990s, and was prohibited from prescribing certain drugs in January 2018 before resigning. McTaggart made 10 recommendations for reform, including stronger oversight of prescribers and better strategies for referring breaches for prosecution. Both sources agree on the timeline of events, Jackson's prescribing practices, and the lack of criminal charges, though the ABC provides additional details about patient testimonies and Jackson's behavior during the inquest.
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Key details reported by multiple sources:
- Dr David Jackson's 'grossly irresponsible prescribing' played a direct causative role in the deaths of Nicholas Brown (35) and Matthew Winwood (47) in Tasmania.
- The four deaths occurred between September 2016 and August 2017: Nicholas Brown (35), Toni Wiki (38), Matthew Winwood (47), and Belinda Kemp (37).
- Dr Jackson prescribed methadone and benzodiazepines to all four deceased patients as part of opioid replacement therapy (ORT).
- A criminal investigation into the deaths resulted in no charges being laid against Dr Jackson, with the Director of Public Prosecutions (DPP) determining in June 2021 that evidence could not sustain convictions for manslaughter.
- Dr Jackson was prohibited from prescribing schedule 4 and schedule 8 drugs by the Australian Health Practitioner Regulation Agency (AHPRA) in January 2018 and resigned from practicing medicine shortly after.
- Coroner Olivia McTaggart made 10 recommendations, including for the Tasmanian Department of Health to develop a 'robust' strategy to refer breaches by prescribers for prosecution.
- Dr Jackson first came to the attention of senior health staff in 1992 for excessive opioid prescribing, and again in 1995 for excessive methadone prescribing.
Points of Difference
Details reported by only one source:
- Dr Jackson displayed a 'permissive approach to opioid prescribing' before the deaths, which had raised concerns from medical professionals since the early 1990s.
- A former colleague, Dr George Cerchez, noted in an affidavit that Dr Jackson 'appeared to be increasing the doses of his pharmacotherapy patients' and was often asked for by name by patients exhibiting drug-seeking behavior.
- A patient known as PX testified that Dr Jackson would replace lost takeaway doses without asking about them and increased her Valium by up to 100 per fortnight 'so she would not pester him'.
- Dr Jackson wrote to AHPRA in May 2017, stating: 'I do not subscribe to the common view that one must never trust a drug addict as they always lie.'
- Dr Jackson remained hostile during the coronial inquest and was unwilling or unable to calmly and thoughtfully analyze matters put to him.
- Dr Jackson prescribed methadone to Nicholas Brown on three occasions without verifying his recent prison prescriptions, putting him in danger.
- Dr Jackson provided 'effectively an unlimited supply for a drug binge' to Matthew Winwood, who was clearly not stable, despite warnings from his mother.
- Coroner McTaggart stated: 'He was deprived of a chance to live at that time.'
- Dr Jackson kept limited notes in relation to treating his patients, making it hard to understand his logic behind prescribing high doses.
Contradictions
Conflicting information between sources:
- The ABC states Dr Jackson's actions were 'grossly negligent' and charges of manslaughter should be considered, while the Guardian only notes the DPP determined evidence could not sustain convictions for manslaughter without further elaboration on the coroner's recommendation.
Source Articles
Doctor's 'grossly irresponsible' prescribing played role in two deaths, coroner finds
A coroner has found a doctor's prescription of drugs to two drug-dependent patients had a "direct causative role" in their deaths. Their report says the doctor had a "permissive approach to opioid prescribing" for more than two decades.
Doctor’s ‘grossly irresponsible prescribing’ played direct role in two deaths, Tasmanian coroner finds
Dr David Jackson gave ‘effectively an unlimited supply for a drug binge’ to one addict, inquest finds Get our breaking news email , free app or daily news podcast A former medical practitioner who was the subject of multiple red flags played a direct role in the deaths of two patients through grossly irresponsible drug prescribing, a coroner has found. Nicholas Brown, Matthew Winwood, Toni Wiki and Belinda Kemp, who were all drug dependent, died in Tasmania between September 2016 and August 2017