John Thomas Lawler · Prevention of Future Deaths report

On 12/09/2017 I commenced an investigation into the death of John Thomas Lawler, 80. The investigation concluded at the end of the inquest on 18 November 2019. The conclusion of the inquest was that on 11 August 2017 John Thomas Lawler suffered a fractured neck and spinal cord damage whilst undergoing chiropractic spinal adjustment and subsequent mobilisation. The spinal cord damage led to respiratory depression from which he died at 20:00 hours on 12 August 2017.

Mr Lawler sought chiropractic treatment as he was suffering with an ache in his legs. On 11 August 2017 whilst undergoing a spinal adjustment using a drop table he stated that he could not feel his arms. He was then moved from the prone position on the treatment table to being upright on a chair next to the table. He became less responsive, an ambulance was called and paramedics transported Mr Lawler down the stairs in a carry chair on stair tracks. He was fully immobilised in the ambulance. A CT scan at York District Hospital confirmed he had ankylosis of the cervical spine, a fracture at C4/C5 and dislocation of the facet joints at C4/C5. There was significant narrowing of the spinal canal. Mr Lawler was transferred to Leeds General Infirmary where he underwent an MRI scan on 12 August 2017 which confirmed significant spinal cord compression. Mr Lawler's condition deteriorated and he died at 20.00 hrs that day. A post mortem examination confirmed the immediate cause of death as respiratory depression due to traumatic spinal cord injury and longitudinal ligament ossification with prominent vertebral body posterior osteophyte of C4/C5.

(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.
(2) A review of the requirement for pre-treatment imaging may inform whether a patient is suitable for treatment.
(3) Mr Lawler was mobilised from the treatment table to a chair after loss of sensation in his arms.
(4) Consideration should be given to making First Aid training mandatory for chiropractors