TASother

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Deceased

Nicholas Shane Brown, Toni Lee Wiki, Matthew Wayne Winwood, Belinda Emma Kemp

Demographics

male, female, male, female

Date of death

2016-09-27 to 2017-08-04

Finding date

2026-06-03

Cause of death

Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni Wiki: cardiac arrest from foreign body granulomas due to injecting crushed alprazolam; Belinda Kemp: community-acquired pneumonia (with mixed drug toxicity, emphysema, obesity and dilated cardiomyopathy as contributors); Matthew Winwood: mixed prescription drug toxicity (methadone, olanzapine, pregabalin, benzodiazepines)

AI-generated summary

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda Emma Kemp (37). Expert evidence established Dr J.'s prescribing grossly violated Tasmanian Opioid Pharmacotherapy Program (TOPP) guidelines through excessive takeaway methadone doses to clinically unstable patients, dangerous co-prescription of high-dose benzodiazepines without safety controls, inadequate clinical assessments and reviews, absent urine drug screening, and poor record-keeping. Dr J.'s negligent prescribing directly caused deaths of Brown and Winwood from combined drug toxicity. Kemp died of pneumonia with prescription drug toxicity contributing. Wiki died from cardiac arrest after injecting crushed alprazolam, enabled by the unsafe prescribing environment. The coroner identified systemic failures in prescriber regulation, addiction medicine resourcing, staff supervision, and prescription monitoring compliance. Ten recommendations made to update TOPP guidelines, strengthen prescriber accountability, enhance education and clinical support, and improve resource allocation.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

Unsafe and negligent prescribing practices by Dr J.
Excessive methadone takeaway doses prescribed without demonstrated clinical stability
Co-prescription of methadone with high-dose benzodiazepines contrary to TOPP guidelines
Inadequate initial patient assessment and ongoing clinical reviews
Failure to monitor or require urine drug screening
Poor medical record-keeping and inadequate documentation
Failure to use prescription monitoring system (DORA)
Prescribing without proper Schedule 8 authority in some cases
Inadequate regulation and enforcement by Pharmaceutical Services Branch
Insufficient resourcing of Alcohol and Drug Services
Lack of supervision of nurse Jacometti by Salvation Army
Jacometti's lack of training and qualifications in pharmacotherapy
Inadequate communication between prescriber and pharmacists
Failure to refer patients to appropriate specialist services
Failure to refer to ADS when clinically indicated

Coroner's recommendations

Complete review of Tasmanian Opioid Pharmacotherapy Program (TOPP) guidelines (2012) with consideration of work already completed, with due consultation, and finalize new guidelines as soon as possible
Upon implementation of new TOPP guidelines, Department of Health (PSB and ADS) widely promote to prescribers and pharmacists, emphasizing guidelines set required standards for ORT delivery in Tasmania
Department of Health (PSB) review processes for identifying and investigating breaches by prescribers of Poisons Act, regulations and guidelines, and develop robust strategy for referring breaches for prosecution or to AHPRA
Department of Health and Department of Justice review adequacy of information exchange between prisons and community health professionals regarding prescribed medications for prisoners in opioid replacement therapy programs
Department of Health employ sufficient case managers, nurses and educators within ADS to meet community ORT demand and enhance clinical support to private providers
Department of Health create position of Outreach Clinical Educator or equivalent within PSB to provide education on safe prescribing of Schedule 8 and Schedule 4 drugs, promote mandatory TasScript use, and encourage compliance
Department of Health review prescriber compliance with TasScript checking obligations after appropriate operational period and implement enforcement measures if necessary
PSB consider requiring more comprehensive patient information with Section 59E authority applications and review adequacy of standard authority conditions, particularly for high-risk cases
Department of Health develop enhanced incentivization and training systems to encourage medical practitioners to provide opioid replacement therapy
AHPRA disseminate this finding to relevant branches across Australia and Medical Board of Australia for retention in event David Jackson seeks re-registration as medical practitioner

Full text

Official source Archived copy

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