A Tasmanian (Australia's island state) coroner has ruled that Dr David Jackson, a former general practitioner, bears direct responsibility for the deaths of two patients through what she described as "grossly irresponsible" drug prescribing. Coroner Olivia McTaggart found that Jackson prescribed methadone and benzodiazepines to vulnerable, drug-dependent patients without adequate oversight, including providing one patient with what she called "effectively an unlimited supply for a drug binge" despite repeated warnings. Jackson, who practised in Tasmania from 1986 to 2018 and had faced concerns about his prescribing habits as far back as 1992, was banned from prescribing certain drugs in January 2018 and was never charged with a criminal offence; the coroner issued ten recommendations for reform, including stronger mechanisms to refer dangerous prescribers for prosecution.