The death of John Lawler raises serious questions about the regulation of chiropractors,Michael Marshall,The Skeptic

On the 11th of August, 2017, a 79 year old man visited a chiropractor, complaining of a stiff neck and aches in his legs. It wasn’t John Lawler’s first visit to Chiropractic 1st in York – he’d had previous consultations there, and had informed his chiropractor, Arlene Scholten, of his surgical history, including a serious procedure to treat spinal stenosis, involving metal rods being inserted into his spine.

Ms Scholten told Mr Lawler that his symptoms were caused at least in part by a vertebral subluxation complex – a pseudoscientific diagnosis which lies at the heart of chiropractic theory, even as the statutory regulator of chiropractic, the General Chiropractic Council, makes it clear that there is no place for subluxation theory in modern chiropractic care and that chiropractors should not make claims to their patients about subluxations.

During the session, as Ms Scholten performed a chiropractic intervention via a drop table (a chiropractic device a patient is told to lie on, which allows for segments of a table to lower independently while pressure is applied to their body), Mr Lawler complained that he had lost all feeling in his arms. Responding to his distress, Ms Scholten moved him, attempted mouth-to-mouth resuscitation (despite Mr Lawler being conscious and breathing), and phoned for an ambulance. During the call, Ms Scholten told the emergency services that she hadn’t given Mr Lawler any manual adjustments, leaving the paramedics with the impression that he had suffered a stroke – a known risk factor of chiropractic manipulation. In actuality, Ms Scholten had missed or misdiagnosed Mr Lawler’s condition, which was ankylosis or hyperostosis, which had left his spine delicate. As a result, during his treatment Mr Lawler had suffered a fractured neck, and having been given inappropriate emergency care, he died in hospital the next day.

Chiropractic ‘drop table’ – segments of the table can drop independently, causing a chiropractic adjustment

According to a 2019 inquest, had Mr Lawler been treated as a trauma patient rather than a potential stroke patient, he would have survived. Instead, despite his fracture he had been moved by Ms Scholten into a sitting position, his neck repositioned during the misguided attempts to perform mouth-to-mouth, and as the paramedics were given misleading information about the events leading up to his injury, they were unable to properly triage the cause of his distress. On multiple occasions, Ms Scholten told the emergency call handler and the paramedics that she had not performed any manual adjustments on Mr Lawler and failed to mention the drop table intervention; the medical professionals were not aware that Ms Scholten was using a definition of “manual adjustment” that did not preclude the use of a device such as a drop table. Ms Scholten also told the paramedics, on multiple occasions, that she had been attending to Mr Lawler’s mid-back when he first started to complain of a loss of feeling – she later accepted that this was not true, and that she had misled the paramedics.

Unsurprisingly, this case became the subject of a fitness to practice hearing, and Ms Scholten’s conduct was examined. She was found to have misled the call handlers, and she was found to have misled the paramedics. The misleading reports she gave to the medical professionals directly contributed to their inability to give Mr Lawler the care that, according to the inquest, would have saved his life.

At the outcome of the hearing, Ms Scholten was cleared of unacceptable professional conduct, and it was ruled that her actions had not fallen short of the standard required of a registered chiropractor. As the Daily Mail reported, she was “free to carry on working” – indeed, there is nothing in the ruling to prevent Ms Scholten treating other elderly patients with degenerative spinal conditions.

The decision to clear Ms Scholten of unprofessional conduct was met with some understandable astonishment and outrage – after all, the harms of chiropractic don’t get any starker than the death of a patient as a result of chiropractic treatment. The outcome of the case is available to read in full, and a close reading of it reveals significant flaws that may shed some light on why further action wasn’t taken by the Professional Conduct Committee – the independent body who evaluates fitness to practice cases brought by the General Chiropractic Council.

Causation not considered

Firstly, and perhaps most crucially, while it was accepted that Mr Lawler’s death was due to “a fracture of his cervical spine (a broken neck) and catastrophic damage to his spinal cord”, what caused Mr Lawler’s fracture was never the subject of the hearing. Instead, the charges put to Ms Scholten were that she performed treatment on Mr Lawler, that he expressed discomfort during the treatment, and that she gave inaccurate and misleading reports to the call handlers, the paramedics, and in her subsequent patient records.

Essentially, the Professional Conduct Committee concerned itself with Ms Scholten’s conduct after Mr Lawler died – yet Mr Lawler’s neck fracture has to have been linked to the treatment he received in Ms Scholten’s clinic, unless anyone intends to argue that it was purely coincidental. Had Mr Lawler not visited Ms Scholten for treatment on August 11th, he would likely not have died on that day. Without looking at the cause of Mr Lawler’s fracture – and, by extent, considering that chiropractic manipulation is actively contraindicated for his condition because of the risks it posed to his weakened spine – any assessment of the responsibility of the chiropractor in question must be flawed.

At no point in the proceedings was it considered that chiropractic treatment is neither an effective nor safe treatment for the spinal condition the patient had, even though Ms Scholten had been made aware of the patient’s condition and prior medical treatment. And as such, it is unclear (because the PCC did not consider) to what degree Ms Scholten was aware of or understood the condition of the patient’s neck and spine, and the vulnerability of it, before she adjusted his spine via her drop table. These seem like fundamental questions to address, if the goal is to protect the public from misleading and potentially harmful healthcare interventions.

It is important to note that it is entirely possible to argue that Ms Scholten’s treatment caused Mr Lawler’s fracture without needing to prove that this outcome was intentional; a chiropractor could be entirely persuaded that their treatments are safe and effective, while being sincerely but fatally wrong on both counts.

Misleading the emergency responders

On a similar note, the committee found that while Ms Scholten repeatedly misled the medical teams aiming to give Mr Lawler emergency care, this did not amount to unprofessional conduct, because they could not prove that she deliberately and intentionally misled them – even though the outcome of her misleading statements was that her patient did not get the trauma care they needed, and subsequently died. According to Ms Scholten’s legal team, her misleading statements were due to a temporary dissociative amnesia brought on by an acute stress reaction to the situation.

It was not considered at any point by the PCC that, had Ms Scholten told the 999 team or the paramedics what her treatment had involved, he would likely have been treated for a spinal injury and (according to the inquest) would likely not have died on that day. This, again, sets the bar for unprofessional conduct inappropriately high. Whether Ms Scholten misled defensively and deliberately, or due to an acute stress response, or for any other entirely innocent reason, is irrelevant; you don’t have to intend to cause harm in order for cause and be responsible for causing harm.

A complaints procedure focused on protecting the public from harm has to be able to take this into account, because a complaints procedure that can only take action in cases of deliberate and intentional harm is too narrow to be of any real use in protecting the public.

Inappropriately expert witnesses

There were other concerning aspects of the hearing, too. For example, the only expert witnesses called in to assess whether what Ms Scholten did was safe and standard care were chiropractors. This is particularly problematic, given that the Professional Conduct Committee – which is independent from the General Chiropractic Council – consists of a mix of lay members and chiropractors. In this case, as in other cases where the conduct and misleading health claims of chiropractors is concerned, it was down to chiropractors to explain to a panel largely consisting of other chiropractors whether the chiropractor’s conduct was reasonable or not.

Quite aside from any potential conflict of interest or desire to defend the chiropractic profession, witnesses whose only expertise is in chiropractic practice are likely to suffer from gaps in understanding regarding the safety, efficacy and limitations of chiropractic care, and are unlikely to have the same depth of medical knowledge of qualified medical experts who specialise in a relevant field.

The case of Mr Lawler demonstrates the folly of this approach, given that chiropractic is not an effective treatment for the condition Mr Lawler had – in fact, it is likely to be contraindicated due to the risk it poses to a weakened spine. Whether Mr Lawler’s treatment was carried out to the satisfaction of a chiropractor is not the point – in this case, the treatment was unnecessary, ineffective, and caused the fracture of a patient’s spine, which then led to his death. However, because the expert witnesses were not medical experts, let alone specialists with expert knowledge of spinal care, the decision gave undue weight to an inappropriate level of expertise. For example:

130.  It is important to emphasise that this is not a case about causation. Both experts, Mr Brown and Mr Young, agree that a fractured neck was an entirely unforeseeable consequence of the treatment being provided by Mrs Scholten.

Had the committee called as experts spinal specialists with a medical background in the condition Mr Lawler had, they may perhaps have arrived at a different conclusion as to the likely causal link between the use of a drop table and the patient’s fractured neck, and how foreseeable a consequence the fracture was. In this case, it appears to have been a critical point in clearing Ms Scholten, as the written decision makes clear:

133.  The Committee considered it possible that on some sub-conscious level there may have been an element of self-preservation due to a misconceived fear that she had somehow been responsible for Patient A’s deteriorating condition, even if there was no foreseeable reason why that might be so. [my emphasis]

Is it fair to describe it a “misconceived fear” that a drop table adjustment to a patient’s weakened spine caused a fracture in the patient’s spine? And were there any foreseeable reasons why a drop table adjustment might have been responsible for the patient’s distress? These, I would argue, are questions for a healthcare practitioner who is sufficiently qualified and expert in the condition Mr Lawler had. Yet the value placed on the testimony from the two chiropractors called as experts seems to have been key:

143.  …The Committee, therefore, agreed with the GCC’s expert witness Mr Brown and did not think Mrs Scholten’s conduct fell far short of the standard required of a registered chiropractor.

This case is a clear example of the problems inherent in judging the appropriateness and safety of chiropractic manipulation based on the opinions of witnesses who are part of the chiropractic profession. Ultimately, when it comes to properly protecting the public, the issue at stake is not whether Ms Scholten carried out chiropractic treatment to the satisfaction of other chiropractors, but whether that treatment was appropriate, safe and effective.

This lack of consideration of medical expertise is an issue elsewhere in the decision, when commending Ms Scholten for taking actions to try to aid Mr Lawler once she had acknowledged his distress:

138. In the Committee’s view, Mrs Scholten did take some appropriate action in relation to Patient A, such as calling for an ambulance and providing resuscitation.

The Professional Conduct Committee considers it to Ms Scholten’s credit that she performed resuscitation on Mr Lawler – despite the fact that he was conscious, breathing and had suffered a trauma to his neck. As was made clear at the inquest, if Mr Lawler had been treated as a trauma patient, and thus kept in place until his neck could be properly secured, he may not have died that day. Sitting Mr Lawler up to administer mouth to mouth, while undoubtedly done with the best of intentions, was inappropriate, and it’s hard to avoid the conclusion that it contributed to his paralysis and death. A properly trained healthcare professional would have recognised this.

Patient testimonies and character references

Elsewhere, the Committee accepted as evidence from Ms Scholten a tranche of personal statements and customer testimonies in order to demonstrate that while she did indeed mislead the healthcare professionals over Mr Lawler’s condition, she didn’t do it deliberately. The relevance of these customer testimonials ought to have been marginal – at best, they could evidence that she’d never been known to deceive paramedics in the past. Had the Committee considered the broader question of what role Ms Scholten had in the fate of the patient who died from trauma sustained during her treatment, such testimonies would have had minimal relevance. However, it seems like the character references had a serious impact:

71.  When considering Mrs Scholten’s credibility and reliability as a witness the Committee took into account her good character and the many references and testimonials attesting to her skill as a chiropractor and her honest character. Indeed, the Committee had never before encountered such an impressive collection of character evidence, which it considered particularly noteworthy. Their authors spoke of Mrs Scholten’s high values and ideals, of her professionalism, of the gentle way in which she treats patients and about how kind and caring she is. They spoke of her integrity both as a chiropractor and as an individual.

It’s important to make clear that nothing written here is aimed at casting doubt on Ms Scholten’s integrity, because her integrity is simply not the point: from the evidence submitted to the hearing and the evidence found at inquest, Ms Scholten performed a drop table adjustment on a patient with a vulnerable spine; a contraindicated treatment that was not evidence based, had no hope of being effective, and was administered to relieve a “vertebral subluxation complex” that did not exist. The treatment caused a fracture in his spine, which led to his death. She was then found by the PCC to have given (even if unintentionally) misleading information to the 999 call handler and paramedics, which resulted in the patient failing to get the necessary trauma care that might have saved their lives. Whether Ms Scholten sincerely believed he had a vertebral subluxation, and wholeheartedly believed the drop table would ameliorate his symptoms, and whether she misled the paramedics with upmost integrity is entirely beside the point; chiropractic is not effective, was not safe, and led to the death of Mr John Lawler.

That all of this fell below the level of unprofessional conduct raises the question of how high a bar the PCC has set before a chiropractor can be found to have endangered the public. A bar set this highly clearly seems to be a problem – if the General Chiropractic Council have to prove not only that one of their registrants gave dangerously misleading information, but also that they did so knowingly and intentionally, then its ability to protect the public from harmful practices is seriously diminished.

As with all fitness to practice decisions made by registered healthcare bodies, the Professional Standards Authority has the powers to review this decision, and potentially challenge the findings – if they do so, we may see the case revisited. Given the apparent flaws in this decision, with its limited scope, its inappropriate expert witnesses, and its seeming requirement for malicious intent, I sincerely hope it does get reviewed. Ultimately, the goal has to be to prevent another patient from suffering the same fate as John Lawler.

The post The death of John Lawler raises serious questions about the regulation of chiropractors appeared first on The Skeptic.

Mr Lawler suffered a fractured neck, and the chiropractor who administered his treatment was found to have misled medical professionals – yet faces no real punishment.
The post The death of John Lawler raises serious questions about the regulation of chiropractors appeared first on The Skeptic.