In 2017, John Lawler died after receiving a chiropractic neck manipulation. The therapist was not just incompetent at providing first aid to her patient, her clumsy attempts to save his life might even have contributed to his death. Now the General Chiropractic Council (GCC) issued a special bulletin to all registrants setting out in detail the action they must take in relation to first aid:
… it is a requirement of our educational programmes that students are trained to deal with medical emergencies and thereafter it is important that chiropractors keep their knowledge and skills up to date.
We expect all chiropractors to consider their own first aid knowledge and skills and determine whether or not to undertake further specific first aid training. We said that registrants should start by considering whether their first aid skills and knowledge are sufficient, appropriate and current.
Every chiropractor is likely to encounter potential traumatic and medical emergencies at some point in their professional life. Like all registered health care professionals chiropractors have a duty to their patients during emergencies. Chiropractors therefore must recognise, assess and manage the potential for emergency medical and traumatic conditions that may be encountered in chiropractic settings.
Many providers of first aid training are available offering a range of courses delivered in a range of different ways, for example, the Royal College of Chiropractors has partnered with a training provider to provide first aid training courses for chiropractors across the UK: http://bit.ly/rccfirstaid
In September 2020, as part of registrants’ continuing professional development submission to the GCC, we expect to see information from each chiropractor on their first aid knowledge and skills, and the steps taken so they are assured of their competence to administer first aid should the need arise.
_____________________________________________________________________
One could read this statement as an admission that:
- UK chiropractors are currently not adequately trained in first aid,
- chiropractic manipulations can cause medical emergencies,
- and possibly that Mr Lawler lost his life because his chiropractor was incompetent in first aid.
At the same time, I find that the statement comes many months too late and is neither clear nor compelling. Why not making it plain:
- exactly which first aid qualification every UK chiropractor must have
- by what time,
- and state what penalty they will face, if they fail to comply?
And, if the GCC are aware that spinal manipulation can cause serious emergencies, why have they not established a proper reporting scheme for such events so that we all know of the frequency of such risks? Could it be that the son of the deceased John Lawler was correct when he said the GCC “seems to be a little self-regulatory chiropractic bubble where chiropractors regulate chiropractors?” And could it be that I was justified in suspecting that the GCC is not fit for purpose?
What do you think?
36 Responses to Death of a chiropractic patient prompts a reaction by the UK General Chiropractic Council
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That is not enough. Here the MOH requires a mandatory first aid course every 3 years and we as the local association arrange these courses free for our members and make sure to put emphasis on specific topics that they may encounter. leaving this to the Chiropractor decision if or when to take these courses is a joke.
good!
and do you have an adverse event reporting scheme for chiros?
In John Lawler’s case, the patient would still be alive, if the chiro had done just that. But she bent her patient’s head backwards after having broken his neck.
I disagree.
Mr Lawler’s neck should never have been ‘adjusted’ in the first place.
Symptoms came on when he was placed face down – his forehead supported at the edge of a hole in the table and his shoulders at the other side. (As for massage tables.)
His neck was thus bridged across the gap.
A section of the table was then dropped (it is caused a ‘drop technique’ – designed to move the spine.)
Given he had extensive spinal osteoarthritis, as was already diagnosed by the chiropractor,, it was inevitable his neck would ‘snap’.
Her failure to treat him thereafter compounded the injury, but the damage (fractured spine/cord damage), was caused by the initial chiropractic treatment.
Mr John Brown, expert chiropractic witness told the coroner’s inquest such treatment was not outwith regular chiropractic practice.
We should all be afraid. Very afraid.
Brown confirmed that potentially fatal mistakes are “not outwith regular chiropractic practice.”
!!!!
BUT WE KNEW THAT BEFORE HE CONFIRMED IT
@Dr. G. Almog
Can you provide a list of the “specific topics that they may encounter”?
Thanks.
Chiropractic first aid, rub temples and phone someone
No there is no organized registry for AE, not for Chiro’s nor for any other profession I know off here in Israel. However, we as a non-governing body are attempting to follow these cases and encourage our members to send us anonymous reports which I present twice a year in our conferences. This April I am presenting the issue of cervical spine SMT AE in the Israeli Spine Society conference (ortho & neuro surgeons mainly) in Eilat… so we are not oblivious to the issue on the other hand we try to keep it under the right proportions.
How can you follow cases that have not been reported?
I can not…
exactly.
and what percentage of chiros report their own mishaps?
and what percentage of chiros do not even know about them? injured patients tend not to return; and the dead ones cannot.
We are indeed far from perfect but we are not the dangerous careless charlatan bunch you guys depict us as.
are you sure?
why have chiropractors not established a reporting system despite experts calling for one since decades???
So again, there is a reporting system that is far from perfect…but please, enlighten me, do you know of a reporting system for NSAID’s AE? Or for Opiates? … do you know of a reporting system for AE following surgeries? I would love to learn
let’s be clear: a reporting system that is not accessible is no reporting system.
and yes, conventional medicine has such systems: https://yellowcard.mhra.gov.uk/
quating a wise man… “How can you follow cases that have not been reported?” nevermind we can agree that the GCC act is not enough…
@ G. Almog on Friday 07 February 2020 at 10:17
“We are indeed far from perfect but we are not the dangerous careless charlatan bunch you guys depict us as.”
Chiros are, by definition, charlatans. When you have evidence of its efficacy for anything, it will be a first.
Don’t be a tool all your life have a day off
Utterly heartbreaking, I am not aware of the inquest, which presumably has been adjourned for criminal investigation? Does anyone know?
my last summary of events is here:
https://edzardernst.com/2019/11/death-by-chiropractic-neck-manipulation-more-details-on-the-lawler-case/
Apparently the inquest was concluded in November last year, right underneath my nose, I was not even aware of it.
apparently no recommendation for criminal prosecution.
I am astonished.
yes, we all were.
Interesting that the GCC doesn’t specifically recommend its members should read this book by “Dr” Harry A. Willett.
It has just two short reviews on amazon uk. The first reads: “good ol time chiro stuff” and the second says: “Semi helpful book. Watch out though, the person who is trying to preform the treatment on you, could end up making matters worse.” Between them, these reviews pretty much sum up the value of chiropractic as a separate “medical profession”.
In the USA, you can purchase a copy of Walter Luebeck’s Reiki For First Aid . So, supported with chiropractic, reiki and at least seven books on homeopathic first aid (plus the kits of homeopathic remedies) widely available in the USA, you can trust to be covered for any emergency. If the recommendations in one of these books don’t work for you, just shift your concept of how the body functions and see what one of the other professionals has to say.
I see the “royal” college of chiropractic are rolling out a series of emergency first aid courses for practitioners across the uk. I wonder though if these will address the issue of – “what to do when you have fractured someones vertebrae” perhaps the efforts would be better directed toward a system of fully informed consent rather than an emergency first aid course.
https://rcc-uk.org/rcc-events/?10050=True&SelectedCPD=Show+selected+CPD+events#selected_events
At least if they get first-aid training they’ll be getting some medical training.
° Admitting the need for first aid training for chriopractors means admitting that there is an increased risk associated with their services, right?
° Risks should be weighed against benefits, right?
° Neck manipulation has failed to show clinical benefit in properly performed trials, right?
° Are chiropractors generally admitting the manipulation associated risks? My understanding is that they are not. Am I correct?
° If neck manipulation were a drug, adverse event case histories would be accumulating in the pharmacovigilance systems that are in place all over the civilised world, right?
>>Yes Mr. Almog, there are systems in place, monitoring drug safety before,
during and after marketing of pharmaceuticals – all over the world.
Researchers and physicians are required by law to report adverse events and side effects.
Here is an example from Norway: https://legemiddelverket.no/english/pharmacovigilance.
° National regulatory authorities communicate over boarders, so the worldwide accumulation of reports of (chiropractic) manipulation-associated stroke and other adverse events would by now have caused alarm, right?
° If case reports of very serious cases of manipulation related stroke were accumulating in manipulation-vigilance monitoring databases around the world, how do you think regulatory authorities wouldrespond?
° Chiropractors like to point to Vioxx as an example when they promote or defend their “drugless” services. Post marketing surveillance of Vioxx revealed a larger than expected accumulation of adverse events in subgroups of long term + high dose users. Vioxx ended up in the proverbial dustbin. Evenso, the risk increase with Vioxx over other drugs in the same family is not large when used with due caution. The main reason for the “demise” of Vioxx was that the manufacturer was found guilty of misconduct in the pre-marketing trials, not that the risk/ benefit ratio of Vioxx was unsatisfactory with proper use.
° Are there any chiromanipulation-vigilance systems? Am I right that there are no such systems anywhere?
° If chiropractors are concerned enough about the safety of their clients to hold first-aid classes, why are they not monitoring the safety of their methods and means like the medical health care system?
° First aid response training will not prevent neck manipulation associated stroke, right?
– It may however contribute to the survival of a brainstem stroke victim, which can at times be worse than death.
° Not manipulating a neck, especially a symptomatic one, is the only way of preventing manipulation related stroke, right?
– So why are we seeing reports of neck manipulation associated stroke in news media and not in chiropractic community media?
I don’t think so. While there is an increased risk associated with their services this correlation is not a valid one.
I work in an IT company. We have lots of people sitting at computers. We also have a policy where at least 2 people per floor have had first aid training. This is just common sense practice in my mind.
Prof. Ernst wrote: “could it be that I was justified in suspecting that the GCC is not fit for purpose?”
IMO, you were wholly justified. A few of my own examples as to why the GCC is not fit for purpose include:
Its failure (despite repeated requests) to publish Appendix A in this link:
https://edzardernst.com/2019/11/the-gcc-seems-to-be-a-little-self-regulatory-chiropractic-bubble-where-chiropractors-regulate-chiropractors/#comment-118534
Its failure to advise (despite repeated requests since the end of 2019) if any of these chiropractors are actual medical doctors:
https://sotoeurope.org/board-members
Its failure to advise, when asked, if ‘Doc’ Michael Lezua holds a medical degree or a Phd:
https://www.putneychiropractic.co.uk/monday-motivation-december-16th/
Its failure to provide evidence for a claim by its registrant, Patricia (Tricia) Hobb, that “the body has an innate energy. Ideally this vital energy should flow freely but any unprocessed physical or emotional trauma is stored in the body causing blockages”:
https://getwell.solutions/talks/
Its failure to comment on these registered chiropractors’ claims that “We do not offer to diagnose or treat any disease or condition other than vertebral subluxations” in the Terms of Acceptance here:
http://www.discover-chiropractic.net/hylnet/clientapp/patientsforms.php
Its inconsistency regarding its refusal to comment on the dubious Vegatest Machine because it wasn’t ‘appropriate to comment on a commercial product’ https://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1172-gcc-refuses-to-comment-on-vegatest-machine.html
…yet it issued this statement (in tandem with the General Osteopathic Council) that strongly condemned a commercial product that was critical of chiropractic and osteopathy:
https://tinyurl.com/vr9grma
Most of these are recent examples of my enquiries and represent the tip of a very large iceberg.
It might be more pertinent to ask whether “Doc” Michael Lezua has the type of “Doctorate” held by “Dr” Gillian McKeith – and by Dr Ben Goldacre’s cat (deceased). There are many staff with PhDs, such as Clinical Scientists, working in the NHS. There is no objection to their using the title Dr as long as they do not try to pass themselves off as medical practitioners.
As Ben also said, “Gillian McKeith, or to give her her full medical title, Gillian McKeith.”
“We expect all chiropractors to consider their own first aid knowledge and skills and determine whether or not to undertake further specific first aid training. We said that registrants should start by considering whether their first aid skills and knowledge are sufficient, appropriate and current.”
This is moving all responsibility away from the GCC as the regulator and onto the individual chiropractors. That means there will be no consistency and if a member of the public goes to visit a chiropractor they will be taking pot luck as to whether their first aid training is adequate or not. If something goes wrong, such as happened in the John Lawler case, the GCC will claim that they have issued “guidance” and that the blame lies with the individual chiropractor. This doesn’t seem appropriate for a professional regulator and is actually unfair on their chiropractic registrants. They should instead have given specific guidance on what is and is not appropriate in terms of first aid training. I therefore agree with your point questioning whether the GCC is fit for purpose as a regulator.
It is not possible to regulate practice founded on fantasy and currently promoted by pseudo science.
That is the problem.
We do now know what the chiropractor implicated, Miss Karen Scholten, did:
(i) She allowed Mr Lawler to believe she was a ‘doctor’. That is how she styled herself.
(ii) She did not obtain informed consent.
(ii) Given the spine is a single column, forces applied at one place may have distant effects.
Mr Lawler was lying face down on a table which dropped – his face/head would have been on a cut-out section for comfort as he lay.
When his thoracic spine was manipulated, dropped or had an ‘Activator’ applied, force would necessarily been applied to his head, and neck.
His neck would have been pressed into hyperextension (he was already kyphotic – neck bent forward – as Miss Scholten had correctly diagnosed) – with the outcome he had.
What did she think she was doing?
For Mr John Brown, as an expert witness, to opine that there was no causal link between the treatment and the damage to spine and spinal cord (even if it is the case the cervical spine itself was not directly manipulated), beggars belief.
And for the police to accept such an opinion is unacceptable.
Mr Brown opined he has never experienced such an event.
Very well – that is because no chiropractor acting responsibly would ever consider doing such a thing as to manipulate a 80 year old kyphotic spondylotic spine in this way.
Would they?
Bolam in spades, and Bolitho too – because even if a body of chiropractors could be found who would have carried out such a procedure, it would not have been reasonable for them to have done so.
In this particular case – an 80 year old with a kyphotic cervical spine and evidence of spondylitis elsewhere in the spine previously treated by surgical instrumentation.
On the face of it, Mr Brown’s evidence is highly partial and non-compliant, contrary to the rules of evidence for expert witness that they should have no conflicts of interest.
He claims to have reported on 500 cases of alleged chiropractic clinical negligence.
With what outcome? That is, in how many cases did he opine there had been negligence?
I note Miss Scholten no longer styles herself ‘Dr’.
Why not? Does this not imply she accepts she was passing off?
Mr Brown’s current web site makes no claim he is a ‘Dr’ – but it used to, as during the case of the BCA v. Simon Singh, and he is referred to as ‘Dr’ in various documents.
Has he been seeking to mislead?
My biggest concern is that Mr Brown’s report is remarkably partial – and the police should have recognised that.
They should have had a report from an expert in cervical injuries (which Brown is not).
They have been inappropriately influenced in acting on his report.
Mr Brown’s influence has prevented these matters being aired openly, having him questioned, and with the whole matter of ‘chiropractic treatment’ being properly considered by the police, courts, coroner, the media (Dail Mail in particular), and the public – as a matter of gross negligence.
I understand the GCC have yet to make a final determination, but I do not hold my breath.
Note: The police asked Brown to report on whether the treatment given to Mr Lawler was “appropriate”, in his expert opinion.
He was NOT asked to opine about Gross Negligence Manslaughter – which is the province of the police, CPS and courts.
the regulation of nonsense will result in nonsense.
Richard Rawlins wrote: “Mr Brown opined he has never experienced such an event. Very well – that is because no chiropractor acting responsibly would ever consider doing such a thing as to manipulate a 80 year old kyphotic spondylotic spine in this way. Would they? Bolam in spades, and Bolitho too – because even if a body of chiropractors could be found who would have carried out such a procedure, it would not have been reasonable for them to have done so.”
IMO, it seems that the GCC relies on the use of the word ‘reasonable’ to prevent chiropractors (numbers unknown) from appearing in front of its Professional Conduct Committee. Further, I suspect that Richard (not John) Brown DC (Doctor of Chiropractic), LL.M (Masters Degree in Law), was the chiropractic expert witness who dealt with my complaint about this article in which a chiropractor appeared to endorse raw milk:
https://www.express.co.uk/life-style/life/663130/doctor-advises-stop-drinking-milk-but-is-this-safe
The GCC said that there was no case to answer because it was “consistent with a body of reasonable chiropractic opinion”.
For those who are not aware, Richard brown DC, LL.M, is also the current Secretary General of the World Federation of Chiropractic and holds this dubious view:
QUOTE
“The WFC has unity as one of its core pillars. While it would seem very simple to cut adrift a section of the chiropractic community with whom we disagree, the reality is that this is neither possible nor desirable…The richness of the chiropractic profession lies in its diversity of approaches…Education is delivered differently. The philosophy of chiropractic care takes many forms, some aligned with other health professions, others quite distinct…The WFC values evidence-informed care and promotes research as a means of developing the chiropractic profession.”
Ref: https://www.wfc.org/website/images/wfc/qwr/QWR_2017JUL.pdf (pp 5-6)
All about the money?
I’m not sure that Bowlam has any application here, a. the case resolves the issue (somewhat) of the standard of proof necessary to determine a breach of duty. At its heart, it holds “a similarly qualified professional” which is somewhat problematic. Bolam therefore would hold that only a reasonable body of celtic white witches, could hold forth opinion on the negligent acts of a celtic white witch.
Bolitho is more interesting here for our purposes, it holds that any such “reasonable bodies opinions” must also be “reasonably held” ie they cannot be fanciful and must be verifiable by fact.
That would allow us to pit a real orthopaedic surgeon, or perhaps a physiotherapist against the actions of the chiropractor (or a C of E vicar to comment on the witch – sorry I am finding it hard to put down this metaphor). The issue of course is that any criminal charge here, would be, as you correctly identify, gross negligence manslaughter, for which neither test has complete application. Or at least the application of these cases has not been explored fully in any GNM charge yet brought.
The test for GNM is a 4 stage one that is certainly similar to that of civil negligence:
It was confirmed by the House of Lords in R v Adomako (1995). It is a four-staged test, and the essential elements to be established to prove gross negligence manslaughter are:
The defendant must owe a duty of care towards the deceased.
The defendant must have breached that duty of care.
The breach must have caused or significantly contributed to the death of the deceased.
The breach must be characterised as gross negligence and therefore considered a crime.
Its this last one that is the tickler, ultimately the extent of the negligence is a matter for the bench or the jury by reference to existing practice standards, that may open the door to Bolam and Bolitho but it is not a gateway, it just allows the tests to be persuasive.
I don’t know where you get your information about Mr Brown, however, I would comment that the purpose of an inquest in England as opposed to Scotland, is not to gather evidence for a criminal prosecution. In fact in most cases, the inquest will be adjourned pending any police investigation. Therefore, questions of the extent of negligence are beyond the remit of the tribunal before the coroner, the coroner can therefore, merely explore the causation for death and record this appropriately.
The police would now that they have seemingly abandoned the prosecution, need to find new evidence in the inquest to reopen it. I have to say, as a lawyer, rather than a medic, I find it very hard to understand how the situation with Mr Lawler could have been simply one of temporal coincidence that he died in such circumstances entirely independently of the treatment he was undergoing. Your explanation of hyperextension is one I have seen advanced in other cases to justify injury . i just find it incredible that the coroner could sit comfortably with a such a conclusion.
I am assuming however given that we are the only ones talking about this that the family has no interest in pursuing the matter further.
The General Chiropractic Council has just approved new guidance on First Aid in Emergencies https://www.gcc-uk.org/news/entry/first-aid-in-emergencies
“not intended to cover every situation that you may face”