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Coroner's Jury Concludes That Neck
Manipulation Killed Canadian Woman

Stephen Barrett, M.D.

A coroner's jury, which concluded that Lana Dale Lewis of Toronto was killed by a chiropractic neck manipulation, has ruled that her death was "accidental" rather than "natural." On September 1, 1996, six days after manipulation of her upper neck, Lewis was admitted to Queensway General Hospital suffering from a stroke. She died from another stroke on September 12. The word "accidental" means "not due to natural causes. The issue at the inquest was whether her death was due to natural causes (hardening of the arteries) or an injury to an artery caused by the manipulation. As explained by Amani Oakley, the attorney who represented Lewis's survivors:

An inquest jury in Ontario can only find one of five one-word verdicts: homicide, suicide, accident, natural causes and undetermined. They cannot actually point the finger of blame to anyone, so it is not open to them to make a finding of "death from a chiropractic manipulation. However, they were clearly instructed by the Coroner and other counsel that if they were convinced that the cause of Lana Lewis' stroke was as a result of the neck manipulation, this would be a traumatic origin of the stroke, and their verdict would be 'accident." If they believed that the stroke she died from was as a result of her lifestyle, health condition, etc., then the verdict would be 'natural causes'. If they were not sure which of the two it was, then their finding would be undetermined.

Among other things, the jury recommended that all patients for whom neck manipulation is recommended be informed that risk exists and that the Ministry of Health establish a database for chiropractors and other health professionals to report on neck adjustments. Here is the full report:

Chief Coroner
Province of Ontario

Inquest Touching the Death of Lana Dale Lewis
Jury Verdict and Recommendations

April 2002/January 2004

Verdict of Coroner's Jury

We the undersigned:

Kenneth Hall of Toronto
Sheila Wilson of Toronto
Julia Vance of Tornonto
Wayne Bulkmar of Toronto
Dianne Muthuveren of Toronto
 
the jury serving on the inquest into the death of Lana Dale Lewis, aged 45, held at the Coroner's Inquest Courts, 15 Grosvenor Street, Toronto, Ontario from April 22, 2002 to January 16, 2004 by Dr. Barry McLellan, Coronoer for Toronto, having been duly sowrn, have inquired into and determined the following:
  1. Name of decreased: Lana Dale Lewis
  2. Date and time of death: September 12, 1996 @ 11:35 AM
  3. Place of death: Queensway General Hospital
  4. Cause of death: Stroke -- Thrombosis of left vertebral artery with occipital and cerebellar infarction
  5. By what means: Accident
The verdict was received on the 16th day of January 2004.

Recommendations are directed to the following parties without priority:

Office of the Chief Coroner-Ontario
Ministry of Community Safety and Correctional Services
Ministry of Health
Canadian Memorial Chiropractic College
College of Chiropractic ­ Regulatory Body
Canadian Chiropractic Association
General

Lana Dale Lewis Jury Recommendations.

The following recommendations are not presented in any particular order of priority.

  1. We the jury recommend, based on the lack of available statistics and reliable studies. that the Ministry of Health in conjunction with the Canadian Memorial Chiropractic College and Canadian Chiropractic Association provide funding (or a well designed level 3 retrospective case control study to assess the relationship, if any, between high neck manipulation and stroke/injury and/or serious complications. Funding for this type of research should be contingent on (a) high quality research design with input from clinical epidemiologists and (b) cooperation between the medical and chiropractic communities in the design and conduct of the study.

    If the results of this level 3 study support a statistical relationship between high neck manipulation and stroke/injury and/or serious complications, we the jury recommend that the Ministry of Health fund a level 2 cohort study to better define whether a statistical relationship exists.
  2. We the jury recommend that practitioners (including chiropractors, physiotherapists and physicians/surgeons) prior to performing high neck manipulation obtain written informed consent for an individual treatment, or a course of treatment. The patient must also be provided with an information sheet outlining the possible risk of stroke and/or injury, with instructions for the patient about all symptoms that should result in them seeking further advice from their practitioner or presenting to an emergency department. In addition, the informed consent should also include a section where the practitioner discusses with the patient the taking of x-rays if the treatment involves any spinal manipulations. In the event that the patient refuses to take an x-ray, the patient must sign specifying that the subject of x--rays has been discussed and they have refused.

    In view of our recommendation that informed consent be obtained on all patients undergoing high neck manipulation. and that a section in the informed consent be devoted to the discussion of x-rays. we the jury recommend that this be communicated to an appropriate practitioners by their respective regulatory bodies and that this be part of the curriculum of all relevant University and College programs and that a standardized form be created by each respective governing body and issued to the practitioner for use.
  3. We the jury recommend, based on evidence heard, that practitioners (including chiropractors, physiotherapists, and physicians/surgeons) be informed by their respective regulatory bodies that provocative testing (prior to performing high neck manipulation) has not been demonstrated to be of benefit and should not be performed. Universities and Colleges teaching high neck manipulation should also be teaching their students that these tests have not been demonstrated to be of benefit and should not be performed.
  4. We the jury recommend to foster an improved relationship between the chiropractic and medical community that a committee be established made up of representatives of the chiropractic and medical professions, to promote a constructive dialogue and the sharing of information between the professions to increase understanding and interaction between the profession for the purpose of delivering the best health care to the public.
  5. We the jury recommend as a result of discrepancies and disagreement regarding the handling of tissue/samples that (a) the Coroner's Office confirm and remind its employees and agents of its policies regarding the safe handling and storage of tissues. Also, that organs being harvested for transplantation from potential Coroner's cases should examined using the appropriate imaging technology and findings of such tests be maintained by the Coroner's Office and considered in the autopsy report; (b) the Coroner's Office shall inform experts and parties to an inquest immediately if there has been a loss or spoilation of tissue; and (c) if additional tissues are required by parties outside the Coroner's office that the Coroner's consent is first given prior to the cutting and that all parties are advised immediately of additional slides, Also, that the party cutting additional slides follow the protocol of the Coroner's office in labeling the subsequent slides.
  6. We the jury recommend that the Coroner's Office require its employees and agents who perfom1 autopsies examine all relevant tissues and information prior to proffering an opinion us to the cause of death or writing reports.
  7. We the jury recommend in order to avoid the family feeling kept out of the loop that the Coroner's Office adopt a policy that for any death investigation a written report detailing the findings be sent to the next-of-kin in a timely manner. If requested by the family, the Coroner's Office should attempt to accommodate a meeting with the family if there are an)' outstanding concerns.
  8. We the jury recommend to avoid any reflection of impropriety on the part of the Coroner's Office, should a meeting lake place between the Coroner's office and parties with a vested interest, that the family be made aware of a meeting and be given the option of attendance. If such a meeting takes place, minutes of the meeting should be recorded.
  9. We the jury recommend that the seal of the Coroner's Office be used for Government business and not as personal letterhead, for example Curriculum vitae.
  10. We the jury recommend that a standard of practice be established for record keeping which requires the type and specific location of the manipulation performed on patients be a necessary part of chiropractic records. If the technique used is a "named" technique, it should be identified as such. If it is a variation, it must be described sufficiently so that other health practitioners can identify exactly what procedure was used.
  11. We the jury recommend that the Ontario Ministry of Health look into the possibility of establishing an internal database whereby chiropractors, doctors, hospitals, physiotherapists, the Coroner's office and other health practitioners report cervical manipulations. A separate section of the database should be created to report adverse events such as, but not limited to, stroke, transient ischemic attacks, "injury"-- pain lasting more than one week in duration, paralysis, dissections/injury to vertebral arteries and symptoms such as dizziness, nausea and sensory disturbances including sudden changes in visual acuity.
  12. We the jury recommend that any OHIP billings from practitioners of cervical manipulation should include (a) identification of the actual location of manipulation and technique used and (b) the condition for which the treatment is being provided. If recommendation 11 is found to be feasible then this information should also be fed into that database.
  13. We the jury recommend, based on a review of the Clinical Guidelines For Chiropractic Practice in Canada, that the chiropractic professional associations, teaching facilities and regulatory colleges, ensure all of their members maintain their skills by taking mandatory upgrade courses.
  14. We the jury recommend that it may be helpful if a patient after receiving a high neck manipulation remain in the practitioner's care for an appropriate period time prior to leaving the practitioner's facilities. By doing so, this may allow the patient to advise the practitioner of any abnormalities or disturbances.
  15. We the jury recommend, based on the age of the Clinical Guidelines For Chiropractic Practice in Canada submitted into evidence, that the Clinical Guidelines For Chiropractic Practice in Canada be upgraded biennially in order to keep practicing chiropractors current.
  16. We the jury recommend another step to fostering the relationship between doctors and chiropractors that, in instances where there may be a patient health concern, there be communication between the patient's family doctor and chiropractor in order to allow the chiropractor a better understanding of the patient's health prior to proceeding with the treatment or course of treatment.
  17. We the jury recommend, based on the lack available statistics and reliable studies, that the Ministry of Health in conjunction with the Canadian Memorial Chiropractic College and Canadian Chiropractic Association consider working with the Canadian Stroke Consortium when the parameters have been established for a well designed level 3 retrospective case control study to assess the relationship, if any, between high neck manipulation and stroke/injury and/or serious complications.

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This article was posted on January 22, 2004.