MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The tragic case of John Lawler who died after being treated by a chiropractor has been discussed on this blog before. Naturally, it generated much discussion which, however, left many questions unanswered. Today, I am able to answer some of them.

  • Mr Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by considerable external force.
  • The pathologist’s report also shows that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.
  • This is a common abnormality in elderly patients and limits the range of movement of the neck.
  • There was no adequately informed consent by Mr Lawler.
  • Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.
  • There is no reason to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg.
  • The chiropractor used an ‘activator’ which applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.

I have the permission to publish the submissions made to the coroner by the barrister representing the family of Mr Lawler. The barrister’s evidence shows that:

a. The treating chiropractor owed a duty of care to the Deceased, her patient;
b. That duty was breached in that:
i. After the Deceased reported loss of sensation and paralysis in his arms, the only safe and appropriate response was to:
1. Leave him in situ;
2. Await the arrival of the paramedic;
3. Provide an accurate history to the ambulance controller and attending paramedic;
ii. The treating chiropractor, in fact:
1. Manhandled the Deceased from the treatment bed into a sitting position on a chair;
2. Tipped his head backwards and gave “mouth to mouth” breaths;
3. Provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport the Deceased downstairs to the ambulance without stabilising his neck.
c. The risk of death was a reasonably foreseeable consequence of the breach;
d. In the absence of the breach:
iii. The paramedic would have stabilised the neck, in situ, and transported the Deceased on a scoop stretcher;
iv. The deceased would have survived.
e. Having regard to the risk of death involved, the misconduct was grossly negligent so as to be condemned as the serious crime of manslaughter. The decision to intervene as she did, went beyond a very serious mistake or very serious error of judgment having regard to the fact that:
i. She held herself out as a provider of (quasi) medical treatment;
ii. She styled herself as “doctor”, (when she was not entitled to do so);
iii. She intervened without any understanding of the injury she had caused nor any training in how to intervene safely.
___________________________________________________________________________
To put it in blunt layman’s terms, the chiropractor broke Mr Lawler’s neck and, by then moving his head the way she did (she put him into the sitting position and bent his head backwards), may well have caused his death.
Here are five lessons we might learn from this tragic case:
  1. Chiropractors are not medical doctors and should make this perfectly clear to all of their patients.
  2. Elderly patients can have several contra-indications to spinal manipulations. They should therefore think twice before consulting a chiropractor.
  3. A limited range of spinal movement usually is the sign for a chiropractor to intervene. However, this may lead to dramatically bad consequences, if the patient’s para-vertebral ligaments are ossified which happens in about 10% of all elderly individuals.
  4. Chiropractors are by no means exempt from obtaining informed consent. (In the case of Mr Lawler, this would have had to include the information that the neck manipulation carries serious risks and has not shown to work for any type of pain in the leg and might have saved his life, as he then might have refused to accept the treatment.)
  5. Chiropractors are not trained to deal with medical emergencies and must leave that to those healthcare professionals who are fully trained.

45 Responses to Death by chiropractic neck manipulation? More details on the Lawler case

  • I think a sixth lesson is that if you refer a someone to another team for further care, you should not lie about the treatment they have had so far.

  • Also:
    1. There is no credible evidence that chiropractic manipulation of the neck is effective for any condition.
    2. There is compelling evidence that it is potentially harmful, even lethal.
    3. The chiropractic trade has no systematic adverse event reporting system.
    4. Practitioners overestimate their expertise and do not fully understand the appropriate limits on their scope of practice.
    5. Practitioners misperceive themselves as highly trained medical specialists (rather than glorified physiotherapists with only one therapeutic intervention in their bag) and hence misrepresent themselves as such to patients.

    The BCA needs to stop the use of neck manipulation, institute an adverse event reporting system, and introduce an urgent programme of remedial education on scope of practice. If it will not do this it should be shut down.

  • Your additional excerpts present an additional confounder….IF in fact the chiroquacker wasn’t lying about the treatment administered (since it’s a profession OF and ABOUT lying that she was telling the truth to investigators is dubious) but my interest is in the actual “adjustment”. IF in fact she didn’t crank the poor guys neck with the bombastic “rotary break” manipulation chiroquackery is famous for, but in fact used an Activator and/or Drop table, I think it should give us all pause as to the extensive dangers of this artifice. These 2 entrepreneurial-theatrics masquerading-as-healthcare (Activators and Drops) are ALWAYS touted as the safe-alternate adjustment for the elderly and children….albeit pointless theatrics BUT plausible placebo-generators….AND ASSUMED SAFE. This story brings that “safe-haven” into doubt.

    • She used an activator and drop table only. Mrs Lawler was there throughout and witnessed the treatment and its ramifications.

      The chiropractic experts were unable to answer the fundamental paradox that a) forces must be strong enough to move vertebrae and so produce therapeutically beneficial effects, yet b) they are so weak that they cannot do harm.

      Two chiropractors gave evidence: Richard Brown and Martin Young.

  • I note that the expert witness in this case is a chiropractor, Mr Richard Brown (who like Miss Scholten, the chiropractor involved, also styles himself ‘Dr’).

    The North Yorkshire Police has sought Brown’s opinion as to chiropractic treatment – but IMHO they should have sought the opinion of a practitioner professing the profession that the patient Mr John Lawler, thought they professed. That is, a ‘doctor practising medicine’ with a special interest in and experience of spinal pathology.

    Mr Lawler already had surgical instrumentation/rods to stabilise his lower spine. Any 80-year-old almost certainly has spondylolysis in the cervical spine. I cannot imagine any registered medical practitioner attempting to manipulate a neck in these circumstances.

    Did the witness Mr Brown really say he would have carried out such treatment, or it was reasonable to do so? Is that really what the other ‘experts’ who advised the police said? It is important to be quite sure about this, as all patients need to know just what standards the chiropractic profession is working to.

    Did the police obtain any advice from a registered medical practitioner who has experience dealing with comparable patients? (A pathologist advises on pathology, not treatment.)

    Mr Lawler almost certainly did not appreciate that chiropractic is a ‘healthcare system different to that of medicine’ – as D. D. Palmer, the system’s originator clearly stated. I doubt the police or coroner appreciate this either.

    Mr Lawler surely should have been advised of that fact, and of the fact that the consensus of medical opinion is that the ‘subluxations’ which chiropractors claim to ‘adjust’ do not exist.

    And why does Miss Scholten style herself as ‘Dr’- unless it be to ‘pass off’ and claim a professional status to which she is not entitled? Why do chiropractors not style themselves as ‘Ch’ for ‘Chiropractor’. That is what they are. Are they not proud of their profession?

    Mr Brown is a graduate of the Anglo-European College of Chiropractic (‘DC’ – diploma in chiropractic). He has a master’s degree in law (Cardiff LL.M.) I cannot identify any doctorate he has obtained, and I do hope he has not misled the court by passing himself off as a doctor if he does not have that professional status. I reiterate, chiropractic is a different system from that of medicine.

    Patient autonomy requires that all patients have to give informed consent to all treatments – even blood taking.
    Assault otherwise.
    Consent may be verbal, by signification (putting out an arm for phlebotomy), or by a legal guardian. Exceptions in emergencies.
    It is good practice to record the fact consent has been given – the ‘signed consent form’ is really a ‘Record that consent has been obtained’.
    And consent should be fully informed – that is the patient must know and understand all factors any reasonable person would or should consider before consenting. Risks, benefits, status/experience of practitioner, whether research is involved etc. (See the case of Ali).

    In 2018, Dr Bawa-Gaba was convicted of gross negligence manslaughter (and struck off the medical register) because, the criminal court determined, she had failed to secure appropriate experienced assistance when dealing with a child who subsequently died. Presumably, that is the standard which will be applied by this coroner’s court, and should have been applied by the police – irrespective of Mr Brown’s opinion and admission as to the standards reasonably to be expected of chiropractors (of which Mr Lawler was unaware, due to the failure of Miss Scholten to properly advise him).

    For the CPS to decide that a practitioner who breaks the arthritic neck of an elderly man by a violent manoeuvre has not perpetrated an act of gross criminal negligence is bizarre. A court should make that determination. And note the evidence of the paramedic who attended that she failed to stabilise the patient’s neck because Miss Scholten did not give an accurate account of events.

    Just why do chiropractors manipulate necks? The risks are high. In this case, the results of massage and conscientious care surely would have sufficed – or if not, referral to a neurosurgeon was indicated.

    • Interestingly, in its September 2018 Council Meeting papers, the GCC addressed the Williams review into gross negligence manslaughter in healthcare https://www.gov.uk/government/publications/williams-review-into-gross-negligence-manslaughter-in-healthcare and the key issues and recommendations identified by the Williams review that were relevant to the GCC and the initial analysis of GCC’s response to the recommendations:

      “Whilst the recommendations made in relation to gross negligence manslaughter, the review identifies the concerns regarding experts are wider. The GCC should review what it requires from experts in terms of experience and training.”

      For more, see item 7, p.15 here: https://www.gcc-uk.org/assets/council/September_2018_Council_papers_WEBSITE.pdf

    • The case was never referred by the police to the CPS. The police made the decision not to charge Ms Scholten. The case was reviewed under the Victims Right to Review process by another independent police officer, who again decided not to charge.

      There has been a lot more information coming out from the inquest, and the written evidence to be tested. The police investigation concentrated on the initial chiropractic manoeuvre, rather than the follow up. The fact that the police decided not to charge does not / should not preclude the coroner making a finding of unlawful killing.

      • @ David on Saturday 16 November 2019 at 22:21

        If the police in Britain are as competent as the police in Australia, then nothing they decide surprises me any more. In my view, the average copper in Oz is SLIC (stupid, lazy, incompetent and corrupt) and the fundamental principle of democracy (the three pillars) is also corrupted.

        Mr Lawler was killed by this pretend doctor and she must face the legal consequences for the average person to have confidence in the dispassionate operation of the law.

  • Consent may be … by a legal guardian.

    I should clarify here that a legal guardian may give consent on behalf of a minor. In the case of an adult who is not able to give consent themselves, nobody else can give consent on their behalf unless there is a pre-existing Power of Attorney in place. In that situation if there is time the case can be referred to the Court of Protection. Otherwise you have to make the best decision you can, in consultation with relatives and patient advocates, and document everything carefully.

    Exceptions in emergencies

    No exceptions. Emergency treatment without consent is still assault. You just have to hope that this is mitigated by circumstances and that nobody will press charges.

    In 2018, Dr Bawa-Gaba was convicted of gross negligence manslaughter (and struck off the medical register)

    She was struck off in January 2018, but reinstated in August the same year following an appeal. This is a very insteresting case to look at as it highlights a series of systemic failures (including understaffing) in the hospital where she was working which all contributed to the death of the child. She had just returned from maternity leave to find herself in the midst of chaos with no support from senior staff. The reaction of most doctors has been “There, but for the grace of God, go I”.

    For the CPS to decide that a practitioner who breaks the arthritic neck of an elderly man by a violent manoeuvre has not perpetrated an act of gross criminal negligence is bizarre

    The CPS has to base its decision on whether they think that they can secure a conviction, not on whether a criminal act has occurred. The also have to consider whether the case would be in the public interest, though I have no idea how they reach that decision.

    • Still a bizarre decision.
      CPS were content to go for Bawa-Gaba – and succeded in their intentions.
      Why was this case not put to jury?
      (It might yet be.)

  • How many known recorded cases are there of death by manipulating the neck so far ??

  • Links to Dr. Ernst’s articles about Mr. Lawler’s death have been posted on “#The Chiropractic Daily” the blog of one Yolanda Loafer, D.C. Surprisingly, Ms. Loafer frequently links to articles critical of chiropractic – including Dr. Ernst’s.

    On her website, Ms. Loafer claims to have graduated from “medical school.” This is, of course, disingenuous since chiro schools bear no resemblance to actual medical schools.

  • A source for this?

    “if the patient’s para-vertebral ligaments are ossified which happens in about 10% of all elderly individuals.”

    Several sources place OPLL around 1% in elderly male Caucasians.

    Example….https://europepmc.org/abstract/med/28966802

    • Prof Mangham, expert histopathologist, gave evidence that “anterior longitudinal ligament ossification is present in about 10% of the elderly and osteophytes are common in degenerative joint disease”.

      • Thanks, but I am looking for an actual journal reference.

      • obviously the issue here is OPLL and not DISH or osteophytes so your quote is irrelevant

        • Obviously?

          His report continues……”This combination of findings suggest the described entity of diffuse idiopathic skeletal hyperostosis (DISH, or Forestier’s disease or senile ankylosing spondylosis), a condition of ligamentous calcification, (particularly the anterior longitudinal ligament as seen here) with associated disk space preservation and hyperostosis (bone overgrowth).”

          • Ah, if he meant DISH, that’s a different condition with its own prevalence in elderly males.

          • Yes obviously

            If you suggest that in this case Mr. Lawler had DISH and the fracture involved only the ossified ALL than you have to explain the neurological involvement as such cases traumatic as they may be are not considered unstable nor is there any central canal involvement.

            If you refer to a possible fracture of an ossified ligament causing spinal shock you normally refer to OPLL (that is why the K line measurement is only relevant for OPLL and not extra-canal space occupying lesions).

            Two different clinical entities with different prevalence, outcome and causation

  • Sorry for not joining the heated discussion here but I will say two things…

    1. This is a terrible tragedy for the patient and his family but also for the Chiropractor involved. I know in this blog you feel we all grow tails and horns but I am sure the chiropractor involved is devastated like every other clinician losing a patient under such circumstances.

    2. You are quoting here the family barrister claims only! I would suggest bringing the other side claims or even better… wait for the coroner report and discuss FACTS rather than claims.

    • Quote: “This is a terrible tragedy for the patient and his family but also for the Chiropractor involved.”

      @ Mr. Almog:
      Are you serious?!
      An innocent, trusting patient is dead and a fake doctor is shedding self-pity crocodile tears because she mistreated and even killed him and now has to face the consequences.
      I feel for Mr. Lawler´s family and have no empathy for “Dr.” Scholten at all.

  • Yes obviously

    If you suggest that in this case Mr.Lawler had DISH and the fracture involved only the ossified ALL than you have to explain the neurological involvement as such cases traumatic as they may be are not considered unstable nor is there any central canal involvement.

    If you refer to a possible fracture of an ossified ligament causing spinal shock you normally refer to OPLL (that is why the K line measurement is only relevant for OPLL and not extra-canal space occupying lesions).

    These are two distinct clinical entities with different prevalence and causality

    • The expert histopathologist who examined the deceased and the bone samples stated that in his opinion Mr Lawler had DISH, according to the quotes from his report above.

      The forensic neuropathology consultant, Dr McKenzie, stated that: “The pattern of pathology in the cervical cord is of a contusion ie a traumatic abnormality at the level of C4/C5, with secondary ischaemic change in the form of anterior spinal artery territory infarction, extending in a rostral direction to approximately the level of C3.”
      There was narrowing of the anteroposterior diameter of the spinal canal to approximately 5.5mm.

      iPhones and large reports on PDF don’t play well for me I’m afraid but if I can help with anything else from the case?

  • this was just tweeted:
    “The coroner Jonathan Heath returned a narrative conclusion that Mr Lawler suffered a fractured neck and spinal cord injury while undergoing (chiropractic) treatment.”

      • Here is the full statement from Mr Lawler’s family this morning (permission has been given to use it):

        QUOTE

        “We were devastated to lose John in such tragic and unforeseen circumstances two years ago. A much-loved husband, father and grandfather, he continues to be greatly missed by all of us. Having to re-live the circumstances of his death has been particularly difficult for us but we are grateful to have a clearer picture of the events that led to John’s death. We would like to take this opportunity to thank the coroner’s team, our legal representatives and our wider family and friends for their guidance, empathy and sensitivity throughout this process.

        There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck.

        Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment.

        The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient.

        It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”.

        Immediately John reported loss of sensation and paralysis in his arms. At this stage the only safe and appropriate response was to leave him on the treatment bed and await the arrival of the paramedics, and provide an accurate history to the ambulance controller and paramedics. The chiropractor, in fact, manhandled John from the treatment bed into a chair; then tipped his head backwards and gave “mouth to mouth” breaths. She provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport John downstairs to the ambulance without stabilising his neck. If the paramedics had been given the full and accurate story, they would have stabilised his neck in situ and transported him on a scoop stretcher – and he would have subsequently survived.

        The General Chiropractic Council decided not to suspend the chiropractor from practicing in September 2017. They heard evidence from the chiropractor that she had “not touched the neck during the appointment” and from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed. We have heard this week that this is incorrect. The family was not allowed to attend or give evidence at that hearing, and we are waiting – now 2 years further on – for the GCC to complete their investigations.

        We hope that the publicity surrounding this event will highlight the dangers of chiropractic, especially in the elderly and those with already compromised spines. We would again urge the regulator to take immediate measures to ensure that the profession is properly controlled: that chiropractors are prevented from styling themselves as medical professionals; that patients are fully informed and consent to the risks involved; that imaging is done before certain procedures and on high risk clients; and that the limits of the benefits chiropractic can provide are fully explored.”

  • From the GCC: Statement following the Inquest into the death of Mr John Lawler

    The General Chiropractic Council (GCC) was notified in August 2017 of the death of Mr John Lawler. An Inquest into his death was undertaken by the Coroner on 11-18 November 2019. Today the Coroner published his findings.

    These are sad circumstances. It has been difficult hearing the testimony of those affected and our sympathy goes to the whole family. The GCC followed the proceedings carefully each day. Following the completion of the Inquest we are now in a position to resume the investigation opened in 2017 following the death of Mr Lawler.

    We must consider the Coroner’s findings carefully as we take our next steps. The case will be prepared for consideration by the GCC Investigating Committee for it to decide whether a hearing into the chiropractor’s fitness to practise be held. We will progress this matter as swiftly as possible.

    We look forward to receiving the Coroner’s report on steps that might prevent deaths in the future.

    • From the Lawler family’s statement: “The General Chiropractic Council decided not to suspend the chiropractor from practicing in September 2017. They heard evidence from the chiropractor that she had “not touched the neck during the appointment” and from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed. We have heard this week that this is incorrect.”

      IMO, the General Chiropractic Council needs investigated.

  • What proportion of the world do you think self-manipulates their necks and why would they do so?

    • not beyond the physiological range of motion!

      • No one has answered my question which is certainly relevant to this discussion including your response Prof. Ernst.
        We see people in public, in private even in their cars self manipulating their necks. Either by rotating their heads quickly or even using their hands under their jaw and back of head. Considering, the evidence that is continually presented or refuted, why would people do this to themselves?

        • I DID ANSWER IT: they do it within the range of motion [therefore it has little relevance to what chiros tend to do to their patients]

          • I asked why do people self manipulate not what degree of force or movement is being applied. No one will answer this.

          • if that question is so important to you, do some research and find out. it seems interesting only to you, so you are the ideal person to carry out the research. [be warned, you might not get a Nobel for it]

        • Robin. That is an intriguing question. I am not aware of any research on that specific topic, thus, it would be interesting to see the research to back up Ernst’s claim (I think he made it up, but I am open to see the evidence).

          I also see that Ernst failed to address the why in your question, but rather told you to go find it out for yourself. That is a strange response considering how much time he has supposedly looked into spinal manipulation and his repeated posting that it’s probably just a placebo.

          I also see that thus far no other so called skeptic has chimed in. Interesting is the silence.

          I eagerly await to see Ernst evidence.

          “they (the layperson) do it (self manipulation) within the range of motion (of the spine).”

  • Hello Doctor Ernst, it is important to clarify it was a THORACIC manipulation (NOT cervical) that was a causative factor in Mr Lawler’s injuries. I noticed other commenters have made the same assumption. Research suggests even mild forces can create spinal fractures in ossified ligaments. Very tragic in any case.

    More reading on fractures associated with ossified longitudinal ligaments can be found here:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347267/
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230657/

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