It has been reported that a woman who suffered a severe headache after injuring her neck during a workout died following a visit to a chiropractor. Joanna Kowalczyk, aged 29, declined a procedure at hospital for her injury and chose instead to try chiropractic. Her medical history showed she regularly suffered migraines and joint hypermobility issues. She also had an undiagnosed connective tissue disorder which made her susceptible to arterial dissections.
Ms Kowalczyk told the chiropractor that she had discharged herself from hospital. The chiropractor was unaware of her medical history but nevertheless manipulated her neck. It is thought Ms Kowalczyk suffered an arterial dissection when she injured her neck in the gym and that she suffered acute dissections to the same location when a chiropractor cracked her neck. She died on October 19, 2021, at Gateshead’s Queen Elizabeth Hospital several days after her chiropractic treatment.
Now her coroner has raised concerns that chiropractors aren’t required to check patient medical records after Ms Kowalczyk’s death. Specifically, the coroner’s report raised two matters of concern:
1. The evidence from the attending paramedic was that she was not aware that symptoms of a stroke can stop after a short time as clearly set out on NHS website and guidance, and that this was not part of her training. This was directly contrary to the Head of Operations’ evidence that this was part of both paramedic training and annual continuing professional development. This was a concerning feature given the accepted evidence of the time critical period to treat patients with symptoms potentially indicative of stroke.
2. The evidence on behalf of the treating chiropractor was that he did not consider it necessary to request GP records or hospital records, before assessment or treatment despite being informed about the Deceased’s recent hospital attendance, investigation which was recommended, and her discharge against medical advice. Even in the updated consent form I have been provided with, which was designed by the British Chiropractic Association, there is no prompt or question designed for the chiropractor to ask to consider obtaining medical records before assessment or treatment, and when this may be appropriate, and the only reference to medical records is a consent to communicate as deemed necessary for the treatment, and for a report to be sent to the GP after treatment. I am concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken.
Receiving a Regulation 28 (Prevent Future Deaths) report from the coroner, the GCC stated that the case may raise some concerns for chiropractors and their patients and published the following additional comment:
The chiropractor involved is subject to a GCC investigation, which was paused to allow for the coronial process. This is standard procedure.
It is not appropriate for us to comment further as it could prejudice proceedings. It is inappropriate and unprofessional for chiropractors to speculate publicly on the details of the case, or the identity of the individual involved.
All matters brought to the attention of the GCC are risk assessed and are considered by an Investigating Committee. More about the investigation process.
In her report, the Coroner has asked the GCC to consider the following concern.
(I am) “concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken.”
We will give full and careful consideration to her concern. Given the clinical matters involved, we are seeking expertise (from across the profession, and beyond) to consider the impact of such a step – including on the care and safety of all patients. The Registrar will be writing to the coroner in the next week to set out how her concerns will be considered, and the expected timing of that work.
We have been in contact with leaders from across the profession and are grateful to them all for their support of our proposed approach.
____________________________
The GCC’s main task is the protection of consumers. I have repeatedly pointed out that they seem to have forgotten this and seem to think it is to promote chiropractic in every way they can, e.g.:
- The UK General Chiropractic Council (yet again) protects the chiro rather than the patient
- The General Chiropractic Council “regulates chiropractors to ensure the safety of patients” … well, you could have fooled me!
- Hurray! The new professional standard by the General Chiropractic Council protects UK chiropractors
- Death of a chiropractic patient prompts a reaction by the UK General Chiropractic Council
- The UK General Chiropractic Council: fit for purpose?
- The GCC “seems to be a little self-regulatory chiropractic bubble where chiropractors regulate chiropractors.”
- The death of Mr Lawler highlights the scandals of chiropractic
Let’s hope the GCC takes the occasion of yet another tragic and unnecessary death as a wake-up call for finally getting its act together!
7 Responses to Following the death of a young woman, the UK General Chiropractic Council received a ‘Prevent Future Deaths’ report
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Let us hope the GCC considers all the evidence in the posts you reference – and asks you to attend and speak to those articles.
Why is the chiropractor not identified?
Any putative patients need to know of his/her standards of practise as from now.
But most importantly – why was Mrs K’s neck manipulated? What for?
Pain relief?
No – pain is a symptom.
What was the diagnosis?
What did the chiropractor think he/she was doing?
We must be told.
And is Mrs K’s estate considering civil action for compensation? Or even police action for manslaughter?
“If all you have is a hammer….” You should never be allowed to call yourself a “doctor”.
The DM picked up the story:
https://www.dailymail.co.uk/health/article-14372023/chiropractor-risks-death-warning-experts.html
Such a tragic situation.
What are the factors that would lead an adult concerned enough about health and fitness to be an active gym member, to reject advice of medically qualified persons with medical degrees that took years to obtain, and at great cost, in favour of a Chiropractor?
Is the mindset involved in such a decision a very widespread one? Does it represent average public perception?
Does it say anything about marketing?
In my experience the general public has no idea about the risks of chiropractic and just very simply think back or neck pain = need to see a chiropractor, much as a tooth ache = need to see a dentist to them. The chiro quacks have definitely marketed themselves well.
It certainly seems so…..
This is going to be interesting
The General Chiropractic Council (GCC) has now published its initial response to coroner. See p.16 here for details:
https://www.gcc-uk.org/assets/council/CO250319-00_Council_Meeting_Pack_Mar-25.pdf
It has announced that ‘a small expert group’ has been convened comprising of leaders within the profession and others from outside the profession ‘to ensure that a broad perspective is obtained’. The group will meet on two or three occasions over the next few months, with the first meeting determining the focus of activity and commissioning of any reports or research. It is expected that progress will be reported to the June 2025 meeting of the GCC with final recommendations presented to the September meeting for approval. In its response (p.19) to the coroner, the Chief Executive and Registrar of the GCC declared that it was the Council’s ‘intention’ to carefully consider [your ]findings and ensure that any action that can be taken to prevent a further death or harm to patients in similar circumstances will be.
On p.21, the terms of reference of the review (Draft Review summary) state that the review will explore the technical and clinical nature of sensitive issues identified by the coroner, and in particular her request that we address ‘whether consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations have been undertaken’. It also states that ‘the review will need to consider the relationship between chiropractic treatment and arterial dissection’. It will consider the case for developing best practice guidance to be adopted by the profession, supporting the new Code of Professional Practice and its emphasis on a safety culture – potentially addressing areas such as high-risk patients, history taking and appropriate risk management.
Functions of the Group :
1. Respond to the issues raised by the coroner and determine whether any aspect of chiropractic care including diversified neck adjustments could potentially have caused or contributed to the patient’s death. Consider whether access to medical records would have changed the chiropractor’s approach to treatment (including not undertaking treatment) and/or referral decisions.
2. Consider whether to commission an expert to undertake an up-to-date review of the published research and evidence.
3. Make recommendations on the steps to be taken by the various stakeholders within the system of chiropractic, which is the GCC, professional associations, the Royal College of Chiropractors, and registrants.
4. Members of the reference group will contribute to the success of the review by:
• informing the approach and providing support for the review as a whole
• ensuring advice is available on the key issues
• advising on the quality, limitations and appropriate use of evidence and the quality of that evidence
• highlighting relevant practice and implementation issues relevant to the review signposting to relevant information
• ensuring a focus throughout on how the findings will be used and presented
• assisting in the development of GCC’s recommendations, ensuring they are realistic and based on a consensus
5. Members can expect the GCC to provide secretariat to the expert review group.
The members of the group are then named, complete with their bios.