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SANTA ROSA — A Santa Rosa doctor pleaded not guilty Tuesday in Sonoma County Superior Court to the second-degree murder of four patients by allegedly prescribing dangerously high levels of addictive opioids and narcotics to them in 2016 and 2017.

Dr. Thomas Keller, 72, also pleaded not guilty to elder abuse of a fifth patient between 2014 and 2015 who also died, issuing prescriptions without a legitimate medical purpose to four patients between 2013 and 2018, and nine enhancements alleging he engaged in suspicious opioid prescribing practices.

Keller entered the not guilty pleas after a lengthy bail hearing that disclosed some of Keller's entries about his patients in a private journal.

The case stems from an investigation by the California Department of Justice's Bureau of Medi-Cal Fraud and Elder Abuse. The bureau prosecutes cases of abuse, neglect and fraud against elderly and dependent adults in care facilities.

Deputy Attorney General Tommy Brennan asked Judge Mark Urioste to continue Keller's no-bail status, arguing Keller is a flight risk and a danger to the public's safety. Brennan said Keller faces 70 years to life in prison and the journal entries showed Keller has "complete and utter contempt" for his patients and humanity.

Defense attorney John Cox said requiring Keller to post cash bail violates his client's due process because Keller cannot afford to pay it. Cox asked Urioste to release Keller under his own recognizance.

Urioste ruled that Keller is entitled to bail despite the four murder charges and he set bail at $12 million, $3 million for each of the murder counts.

Urioste then transferred the case to a trial court where Judge Chris Honigsberg set Sept. 3-4 for a preliminary hearing.

The complaint alleges Keller over-prescribed and consistently and drastically increased opioid prescriptions of pain medications including Vicodin, oxycodone, OxyContin, Percoset and morphine at levels well outside accepted medical practice.

Keller allegedly also prescribed Soma, a muscle relaxant, and benzodiazepines that cause a dangerous drug interaction with opioids.

The maximum doses of the drugs were in quantities upwards of 180-300 pills per prescription, and Keller allegedly ignored warnings from pharmacies and insurance companies, his own observations of his patients and knowledge about his patients' overdose deaths, the Attorney General's Office said.

During the bail hearing, Cox said the four alleged murders were actually three suicides and one accidental death. He said some of Keller's patients were very ill or dying and Keller did the best he could for them.

After the hearing, Cox said Keller was very experienced and knowledgeable and the cause of at least one of the deaths is unknown.

"We shouldn't be second guessing doctors. You can't have a murder charge when you can't determine the cause of death," Cox said.

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