Coroner Finds Doctor’s Prescribing Directly Contributed to Two Deaths
A coroner in Tasmania has found that Dr. David Jackson's prescribing practices directly contributed to the deaths of two patients, while a criminal investigation into the deaths did not result in charges.
Coroner Olivia McTaggart examined the deaths of four individuals who were prescribed methadone and benzodiazepines by Dr. Jackson as part of opioid replacement therapy. The deceased were Nicholas Brown (35), Toni Wiki (38), Matthew Winwood (47), and Belinda Kemp (37), who died between September 2016 and August 2017.
Causes of death varied: Kemp died from pneumonia with contributing factors; Wiki from cardiac arrest caused by injecting Xanax; Brown from combined methadone and benzodiazepine intoxication; Winwood from mixed prescription drug toxicity including methadone.
The coroner stated that Dr. Jackson's actions played a direct causative role in the deaths of Brown and Winwood, but not in the deaths of Wiki and Kemp.
'Permissive Approach' to Opioid Prescribing
Dr. Jackson's prescribing was described as having a 'permissive approach to opioid prescribing,' which had been a concern since the early 1990s. The investigation found that Dr. Jackson supplied takeaway methadone doses contrary to guidelines and that excess supply may have contributed to deaths.
Investigators considered his actions 'grossly negligent' and considered manslaughter charges, but the Director of Public Prosecutions determined in June 2021 that evidence could not sustain convictions.
During the inquest, Dr. Jackson was described as hostile, lacking rationality, remorse, and insight into his failings.
Background of Concerns
Dr. Jackson moved from Victoria to Tasmania in 1986. Concerns about his prescribing of excessive opioids began in 1992 at John Edis Hospital, and again in 1995 for excessive methadone prescribing. In 2007, a colleague noted Dr. Jackson was increasing doses for pharmacotherapy patients and was often requested by patients exhibiting drug-seeking behavior. In 2008, he had a disagreement with Pharmaceutical Services Branch over opioid prescriptions.
The former clinical director of Tasmanian Alcohol and Drug Services expressed concern about potential harm from Dr. Jackson's behavior.
Regulatory Action
In March 2017, AHPRA received an anonymous complaint from a pharmacist about Dr. Jackson's excessive takeaway prescriptions for a patient. The patient reported that Dr. Jackson prescribed what she wanted, increased doses over the phone, replaced lost doses without inquiry, and increased Valium to avoid being pestered. Dr. Jackson was known as 'the pill doctor.'
After AHPRA notified him of the complaint, Dr. Jackson contacted the patient and limited her prescriptions. He wrote to AHPRA explaining his prescribing approach, stating he did not subscribe to the view that drug addicts always lie.
In January 2018, Tasmania Police notified AHPRA about Dr. Jackson in connection with Brown's death. AHPRA immediately prohibited him from prescribing schedule 4 and 8 drugs, finding he posed a serious risk. Dr. Jackson resigned from practice that month.
Coroner's Recommendations
The coroner made 10 recommendations, including:
The Department of Health should develop a strategy to refer prescriber breaches for prosecution, and AHPRA should communicate the findings across Australia and to the Medical Board of Australia in case Dr. Jackson seeks re-registration.