TASMANIA — Coroner Olivia McTaggart determined that Dr David Jackson's prescribing practices played a direct causative role in the deaths of Nicholas Brown and Matthew Winwood in Tasmania. Both men died from drug intoxication between September 2016 and August 2017 while under Dr Jackson's care.
Dr Jackson prescribed methadone and benzodiazepines to patients as part of opioid replacement therapy. Nicholas Brown, 35, died from combined methadone and benzodiazepine intoxication. Matthew Winwood, 47, died from mixed prescription drug toxicity involving methadone and multiple sedatives.
"The actions of Dr Jackson, by his grossly irresponsible prescribing, played a direct causative role in the deaths of Mr Brown and Mr Winwood," McTaggart said. "He may have died by drug overdose eventually, such was his high risk, but that is not to the point. He was deprived of a chance to live at that time." Dr Jackson prescribed methadone to Brown on three occasions without verifying his recent prison prescriptions. He also prescribed a large quantity of medication to Winwood despite his clinical instability and warnings from his mother.
Dr Jackson practiced medicine in Tasmania from 1986 to 2018. Concerns regarding his opioid prescribing were raised by senior health staff at a Hobart hospital in 1992. A state pharmacist reviewed Dr Jackson's prescribing practices in 1995 due to excessive methadone prescriptions. In 2007, a colleague questioned Dr Jackson's prescribing practices for drug-addicted patients at a shared health centre. The same colleague reported that Dr Jackson maintained limited patient notes, which complicated the assessment of his logic for prescribing high medication doses.
In January 2018, the national medical regulator prohibited Dr Jackson from prescribing specific drugs following a police notification. He ceased his medical practice in January 2018. The director of public prosecutions for Tasmania determined in 2021 that available evidence could not sustain manslaughter convictions against Dr Jackson.
Coroner McTaggart also found that Dr Jackson did not play a direct role in the deaths of Toni Wiki or Belinda Kemp. Wiki died of cardiac arrest. Kemp died of pneumonia, with mixed drug toxicity and other medical issues contributing. McTaggart issued ten recommendations for healthcare reform, which included directing the Tasmanian health department to develop a strategy for referring prescriber violations for prosecution.