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 issue involved was whether her death was due to natural causes
(hardening of the arteries) or an injury to an artery caused
by the manipulation. For purposes of the inquest, the word "accidental"
means "not due to natural causes. 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:
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This article was posted on January
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:
- Name of decreased: Lana Dale Lewis
- Date and time of death: September 12, 1996 @ 11:35 AM
- Place of death: Queensway General Hospital
- Cause of death: Stroke—Thrombosis of left vertebral artery
with occipital and cerebellar infarction
- By what means: Accident
- The verdict was received on the 16th day of January 2004.
Recommendations are directed to the following parties without
- 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
Lana Dale Lewis Jury Recommendations.
The following recommendations are not presented in any particular
order of priority.
- 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
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- 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.