Coroner’s concerns over death of Gateshead gym-goer following chiropractor treatment
A gym-goer from Gateshead died following treatment from a chiropractor after she suffered a crack to her neck, a coroner has said.
Joanna Kowalczyk, 29, discharged herself from hospital after the gym injury and sought alternative treatment from a chiropractor, who did not see her medical records. During her fourth session with the chiropractor, in October 2021, Ms Kowalczyk felt dizzy, developed double vision, tingling in her right hand and foot, and struggled to speak.
She was eventually able to go home but was taken to hospital the next day, where she later died. Assistant coroner for Gateshead and South Tyneside, Leila Benyounes has now written a prevention of future deaths report to raise concerns that the chiropractor had not seen Ms Kowalczyk’s medical notes before her course of treatment began.
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In the report, the coroner said Ms Kowalczyk died "due to a combination of the consequences of chiropractic treatment following a naturally-occurring medical event, on a background of an undiagnosed medical condition." Ms Kowalczyk’s medical history included migraine and joint hypermobility, and the coroner found it was likely she had an undiagnosed connective tissue disorder which left her susceptible to arterial dissections.
While working out at the gym, it seemed Ms Kowalczyk suffered bilateral arterial dissections when she felt the crack in her neck on September 27, 2021. She sought treatment at the Queen Elizabeth Hospital, Gateshead, the following day. She had a CT scan, but left before a lumbar puncture to diagnose the problem could be carried out.
While in hospital, Ms Kowalcyzk researched alternative treatments and arranged an appointment with a chiropractor for the next day. Ms Kowalczyk told the chiropractor about her hospital visit and that she had self-discharged, and a course of "adjustments and manipulation" began, the coroner said.
During the fourth course of treatment, Ms Kowalczyk "sustained acute dissections in the same location as the previous dissections during the chiropractic manipulation", the coroner reported. The chiropractor was concerned that she had suffered a stroke, but tests proved negative.
Ms Kowalczyk remained at the practice for several hours and was advised to go to hospital by two chiropractors, but she chose not to. She eventually got home with help from her partner, despite being unable to walk properly, and was given a hand-written note from the chiropractor advising her to go to hospital if the symptoms returned.
Later that day, an ambulance was called and paramedics attended as an emergency. She was diagnosed with a migraine, having been checked for signs of a stroke.
She fell "gravely ill" the next day and paramedics took her to hospital, where she died on October 19, 2021. Ms Benyounes was concerned the chiropractor had not thought it necessary to request his patient’s medical records before beginning treatment, despite being told about her recent hospital visit and that she had discharged herself against advice.
The coroner, who also expressed concerns about the attending paramedic’s knowledge of strokes, has asked for a response from the General Chiropractic Council within eight weeks.
In a statement, a General Chiropractic Council spokesman said: "We expect chiropractors to provide good quality care that is patient-centred, safe and effective, and that is consistent with the current standards for good healthcare practice. We will be carefully considering the important concerns raised by the coroner in her report and will respond directly to her."