He was deprived of a chance to live at that time.
In Tasmania, a coroner's inquest has drawn a quiet but devastating line between institutional inaction and human death. For thirty years, warnings about Dr David Jackson's reckless prescribing of opioids and sedatives accumulated without consequence — until two of his patients, Nicholas Brown and Matthew Winwood, died of overdoses between 2016 and 2017. Coroner Olivia McTaggart found his prescribing directly caused both deaths, and now asks whether a system that watched and waited for decades can be rebuilt into one that acts.
- Two men — Nicholas Brown, 35, and Matthew Winwood, 47 — died of prescription drug overdoses while under the care of a doctor whose dangerous habits had been flagged since 1992.
- Jackson prescribed what the coroner called 'effectively an unlimited supply for a drug binge,' often without verifying patients' recent prescription histories or heeding direct warnings from family members.
- Despite red flags raised by hospital staff, pharmacists, and colleagues across three decades, no meaningful regulatory action was taken until police launched a criminal investigation following the deaths.
- Tasmania's director of public prosecutions ultimately declined to pursue manslaughter charges in 2021, leaving accountability to rest on a coroner's findings rather than a courtroom.
- Coroner McTaggart issued ten recommendations for systemic reform, with the sharpest calling on Tasmania to build a clear, enforceable pathway for referring prescriber misconduct to prosecutors.
A Tasmanian coroner has found that a physician's decades-long pattern of reckless prescribing directly caused the deaths of two opioid-dependent patients. Dr David Jackson, who practiced in Tasmania from 1986, gave Nicholas Brown and Matthew Winwood access to methadone and benzodiazepines with what Coroner Olivia McTaggart described as almost no clinical restraint. Brown was 35 when he died of combined methadone and benzodiazepine poisoning. Winwood was 47 when a mixture of prescription sedatives and methadone killed him. Both died between September 2016 and August 2017.
The failures were specific and documented. Jackson prescribed methadone to Brown without checking what drugs he had received in prison. With Winwood, whose own mother had warned the doctor about his deteriorating condition, Jackson continued prescribing with minimal oversight. McTaggart acknowledged Winwood's life was already at high risk — but concluded he had been robbed of a chance to survive that particular moment.
What gave the case its particular weight was the timeline of ignored warnings. Concerns about Jackson's excessive opioid prescribing were raised by hospital staff in 1992, by a chief pharmacist in 1995, and by a colleague in 2007 who noted his near-absent patient records. Each alarm was documented. None produced meaningful consequences.
Only after the deaths of Brown and Winwood did a police investigation prompt the national regulator to restrict Jackson's prescribing in January 2018. He ceased practicing that same month. But when prosecutors reviewed the case in 2021, they found the evidence insufficient for a manslaughter conviction, and no charges were filed.
McTaggart responded with ten recommendations, the most pointed being a call for Tasmania to establish a formal strategy for referring prescriber breaches to prosecutors — an acknowledgment that the system had no reliable mechanism to act on what it had long known. The coroner's findings leave Tasmania with a clear question: whether it will now build the structures that might have saved two lives already lost.
In the quiet aftermath of an inquest, a Tasmanian coroner laid bare a pattern of prescribing so reckless it cost two men their lives. Dr David Jackson, a physician who had practiced in Tasmania since 1986, gave what the coroner described as "effectively an unlimited supply for a drug binge" to patients struggling with addiction—and the system that was supposed to stop him had noticed the problem for decades.
Nicholas Brown was 35 when he died of combined methadone and benzodiazepine poisoning. Matthew Winwood was 47 when mixed prescription drugs, including methadone and multiple sedatives, killed him. Both were opioid-dependent. Both were patients of Jackson's. Both died between September 2016 and August 2017 in Tasmania. Coroner Olivia McTaggart, reviewing the evidence, found that Jackson's prescribing practices played a direct causative role in their deaths. Two other patients under his care—Toni Wiki and Belinda Kemp—also died during this period, though McTaggart determined Jackson's actions did not directly cause their deaths.
The specifics of Jackson's negligence were damning. With Brown, a lifelong drug user, Jackson prescribed methadone on three separate occasions without bothering to verify what prescriptions Brown had recently received while in prison. With Winwood, who was clearly unstable and whose own mother had warned Jackson about his condition, the doctor handed out drugs with almost no restraint. "He may have died by drug overdose eventually, such was his high risk," McTaggart said in her findings, "but that is not to the point. He was deprived of a chance to live at that time."
What made this case particularly striking was not that Jackson was a bad doctor who suddenly went wrong. It was that he had been a problem for thirty years. In 1992, senior staff at a Hobart hospital flagged serious concerns about his excessive prescribing of opioids. In 1995, the chief pharmacist raised alarms again, this time specifically about his methadone prescribing. In 2007, a colleague noted that Jackson kept minimal notes on his patients, making it impossible to understand why he was prescribing such high doses to people with known addiction problems. The red flags were there. They were documented. Nothing substantial happened.
It took the deaths of Brown and Winwood to finally trigger action. Police launched a large-scale criminal investigation. In January 2018, the national regulator prohibited Jackson from prescribing certain drugs based on the police findings. He stopped practicing that same month. But when Tasmania's director of public prosecutions reviewed the case in 2021, they determined the evidence could not sustain a conviction for manslaughter, even though Jackson's prescribing was undeniably dangerous, negligent, and contrary to clinical guidelines. No criminal charges were filed.
McTaggart's response was to issue ten recommendations for systemic reform. The most pointed was a call for Tasmania's health department to establish a robust strategy for referring prescriber breaches to prosecutors—a tacit acknowledgment that the existing system had failed to hold Jackson accountable despite three decades of warning signs. The coroner's findings were clear: a doctor with a documented history of reckless prescribing had been allowed to continue treating vulnerable patients until two of them were dead. The question now was whether Tasmania would build the machinery to prevent it from happening again.
Citações Notáveis
He was deprived of a chance to live at that time.— Coroner Olivia McTaggart, on Matthew Winwood
The actions of Dr Jackson, by his grossly irresponsible prescribing, played a direct causative role in the deaths of Mr Brown and Mr Winwood.— Coroner Olivia McTaggart
A Conversa do Hearth Outra perspectiva sobre a história
Why did it take so long for anyone to stop him? The red flags started in 1992.
The system wasn't designed to escalate. Each concern was noted, filed, and then the machinery just... stopped. There was no mechanism that said: if we see this pattern, we act.
But people died. Doesn't that change the calculus?
It should have. That's what the coroner is saying. Brown and Winwood died because Jackson had been allowed to keep prescribing to vulnerable people for thirty years without real consequences.
The prosecutor said there wasn't enough evidence for manslaughter charges. How is that possible?
The law is narrow. You have to prove Jackson intended harm or showed such reckless disregard that it amounts to criminal negligence. Negligent prescribing—even grossly negligent—can fall short of that threshold. The coroner found he was reckless. The prosecutor found it wasn't criminal enough.
So the coroner's job is to say what happened. The prosecutor's job is to say whether it's a crime.
Exactly. And sometimes those two things don't align. McTaggart made clear Jackson's actions directly caused two deaths. But the law couldn't touch him for it.
What changes now?
That's the real question. The coroner recommended Tasmania build a system to prosecute prescriber breaches. Whether they actually do it is another matter entirely.