General Chiropractic Council

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First report 26 Nov 2019•Latest report 22 Jan 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 2
Published responses: 50%
Concerns addressed: 1
Stated actions: 6

Concerns and recipient responses

Statements from General Chiropractic Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

22 Jan2025
Gateshead and South Tyneside
Concerns raised3
1. Failure to consider obtaining medical records before assessment or treatment
2. Lack of paramedic training on transient stroke symptoms
3. Absence of a consent-form prompt to consider obtaining medical records before assessment or treatment
Actions described in response 1
1. Action
  Agree an Expert Group Action Plan with chiropractic profession representatives to mitigate comparable incidents.
Respondent positions 1
1. Position
  The new Code’s changes would not have materially altered the chiropractor’s expected conduct in this case.
  Disputes the concern
AI-generated summary

Joanna Kowalczyk · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Joanna Kowalczyk developed neurological symptoms after chiropractic neck manipulation following an earlier neck injury and hospital attendance, and was later diagnosed with vertebral artery dissection and extensive posterior fossa infarction. She died at Queen Elizabeth Hospital on 19 October 2021. Concerns included a paramedic’s lack of awareness that stroke symptoms can resolve temporarily, and the chiropractor’s failure to obtain medical or hospital records before treatment despite the recent hospital attendance and recommended investigations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Chiropractic Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider obtaining medical records before assessment or treatment
Wider context from the report
“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. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Chiropractic Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of paramedic training on transient stroke symptoms
Wider context from the report
“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. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Chiropractic Council; that does not assign responsibility.
PFD Monitor interpretation
Absence of a consent-form prompt to consider obtaining medical records before assessment or treatment
Wider context from the report
“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. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Agree an Expert Group Action Plan with chiropractic profession representatives to mitigate comparable incidents.

Verbatim wording from the response
“This letter is to update you on the findings of the Expert Group, and the Action Plan that the GCC and representatives of the chiropractic profession have agreed to take to mitigate against a comparable incident occurring in the future.”

Source location
Response from General Chiropractic Council
Page 1 · response
Published 23 January 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The new Code’s changes would not have materially altered the chiropractor’s expected conduct in this case.

Verbatim wording from the response
“In 2024, the GCC reviewed and updated the standards of proficiency for chiropractors. The new standards were published ahead of the inquest (31 December 2024) but must “sit” for a year before they come into effect (on the 1 January 2026). References to the Code of Professional Practice in this letter, and in the Action Plan, refer to this new document (which was not in place at the time of Joanna’s death). However, we do not believe that the changes to the Code would have made a material difference to the expectations of the chiropractor in this case.”

Source location
Response from General Chiropractic Council
Page 3 · response
Published 23 January 2025
Open published response
26 Nov2019
North Yorkshire and City of York
Concerns raised2
1. Failure to avoid mobilisation after loss of sensation in the arms
2. Lack of pre-treatment spinal imaging
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John Thomas Lawler · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Thomas Lawler suffered a fractured neck and spinal cord damage during chiropractic spinal adjustment and subsequent mobilisation on 11 August 2017. He died from respiratory depression caused by the traumatic spinal cord injury on 12 August 2017. Concerns included the absence of pre-treatment spinal imaging and mobilisation after he reported loss of sensation in his arms.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Chiropractic Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to avoid mobilisation after loss of sensation in the arms
Wider context from the report
“(3) Mr Lawler was mobilised from the treatment table to a chair after loss of sensation in his arms. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Chiropractic Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of pre-treatment spinal imaging
Wider context from the report
“(1) No pre-treatment images were taken of Mr Lawler's spine. Ossification of the spine was not known until post-trauma CT images were obtained. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to consider obtaining medical records before assessment or treatment

Lack of paramedic training on transient stroke symptoms

Absence of a consent-form prompt to consider obtaining medical records before assessment or treatment

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised2

Failure to avoid mobilisation after loss of sensation in the arms

Lack of pre-treatment spinal imaging

Actions described in response 1

Respondent positions 1