Doctor’s ‘grossly irresponsible prescribing’ played direct role in two deaths, Tasmanian coroner finds | Tasmania

Doctor’s ‘grossly irresponsible prescribing’ played direct role in two deaths, Tasmanian coroner finds | Tasmania

June 6, 2026 discoverhiddenusacom Health

A Tasmanian coroner has concluded that the prescribing practices of a former medical practitioner, Dr. David Jackson, played a direct, causative role in the deaths of two patients. The findings follow a comprehensive inquest into the deaths of four drug-dependent individuals—Nicholas Brown, Matthew Winwood, Toni Wiki, and Belinda Kemp—who died in Tasmania between September 2016 and August 2017.

Coroner Olivia McTaggart determined that Dr. Jackson exhibited a “dangerous manner of treatment and prescribing.” While the coroner noted that Dr. Jackson’s actions were not directly responsible for the deaths of Ms. Wiki or Ms. Kemp, the evidence established a clear link between his clinical conduct and the fatalities of Mr. Brown and Mr. Winwood.

Did You Know? Dr. David Jackson’s clinical practices were flagged by health authorities as early as 1992, when senior hospital staff expressed significant concerns regarding his excessive opioid prescribing, followed by a similar alert from a chief pharmacist in 1995.

The Clinical Findings

The inquest highlighted specific instances of negligence in Dr. Jackson’s care. Regarding Nicholas Brown, 35, the coroner found that Dr. Jackson prescribed methadone on three separate occasions without verifying the patient’s recent prison prescriptions, placing the lifelong drug user in significant danger. Mr. Brown ultimately died of combined methadone and benzodiazepine intoxication.

In the case of Matthew Winwood, 47, the coroner stated that Dr. Jackson provided “effectively an unlimited supply for a drug binge.” Despite clear evidence that the patient was not stable and warnings provided by the patient’s mother, the medication was supplied. Mr. Winwood died of mixed prescription drug toxicity involving methadone and multiple sedatives. The coroner observed that while Mr. Winwood was at high risk of overdose, he was effectively “deprived of a chance to live at that time” due to the doctor’s actions.

Expert Insight: The implications of this inquest extend beyond the individual actions of a single practitioner, highlighting critical vulnerabilities in patient oversight. The case underscores the essential role of inter-agency communication and the necessity for rigorous, standardized protocols in managing high-risk opioid replacement therapies to ensure patient safety and professional accountability.

Regulatory and Legal Context

Although Dr. Jackson was the subject of a large-scale criminal investigation, he was not charged. In 2021, the director of public prosecutions determined that the available evidence could not sustain convictions for manslaughter, even while acknowledging that the prescribing behavior was dangerous and contrary to clinical guidelines. Dr. Jackson, who worked in Tasmania from 1986 to 2018, was ultimately prohibited from prescribing certain drugs in January 2018 following police notification, and he ceased practice later that month.

Coroner's toxicologist testifies in trial of Jackson doctor

Future Reform

Following the inquest, Coroner McTaggart issued 10 recommendations for reform. A primary focus of these measures is the establishment of a robust strategy by Tasmania’s health department to ensure that future breaches by prescribers are referred for prosecution. We see likely that these recommendations will prompt a review of current monitoring systems to ensure that red flags are addressed with greater urgency in the future.

Frequently Asked Questions

What was the cause of death for the four patients?
Nicholas Brown died of combined methadone and benzodiazepine intoxication, and Matthew Winwood died of mixed prescription drug toxicity. Toni Wiki died of cardiac arrest, and Belinda Kemp died of pneumonia, with mixed drug toxicity and other issues contributing.

Frequently Asked Questions
Dr David Jackson Tasmania

Did the coroner find Dr. Jackson responsible for all four deaths?
No. The coroner found that Dr. Jackson’s grossly irresponsible prescribing played a direct causative role in the deaths of Mr. Brown and Mr. Winwood, but determined he did not play a direct role in the deaths of Ms. Wiki or Ms. Kemp.

Why was Dr. Jackson not charged with manslaughter?
In 2021, the director of public prosecutions determined that the evidence could not sustain convictions for manslaughter, even though the prescribing practices were identified as dangerous, negligent, or contrary to clinical guidelines.

How might these new recommendations change the way medical oversight is handled in the future?