Lana Lewis was admitted to Queensway General Hospital in Toronto on Sept. 1, 1996, six days after receiving an upper neck manipulation from Dr. Emanuele. Prior to suffering the stroke, she had seen Dr. Emanuele for approximately 18 months, primarily for treatment of migraine headaches and musculoskeletal pain. At Queensway, she was diagnosed as having suffered a minor stroke and was hospitalized briefly, then released. However, approximately 10 days after suffering the first stroke, she suffered a second, larger stroke that proved to be fatal. She was readmitted to Queensway, where she died Sept. 12. The initial coroner's report did not cite the adjustment as the cause of death, and at that time, the Toronto coroner's office decided not to hold an inquest into the cause of Ms. Lewis' death.
Nevertheless, more than three years later, in November 1999, the Lewis family called for an inquest to determine the cause of her death. In January 2000, the family also filed a $12 million civil lawsuit against Dr. Emanuel and a number of chiropractic organizations, citing that they had not advised the public properly about the dangers of neck adjustments. Representing the Lewis family at the time was Murray Katz, MD, a longtime opponent of the chiropractic profession and founder of the National Association of Chiropractic Medicine (NACM). In early 2001, however, Dr. Katz was removed from the case after threatening to end the professional career of a Canadian coroner, Dr. Murray Naiberg.
After the family's request for an inquest was denied twice, the coroner's office reversed its stance and decided an inquest could proceed. Even then, however, it faced a series of delays. In addition to Dr. Katz's removal from the case a second time, the Lewis family's original lawyer excused himself from the proceedings, and several dozen slides of Ms. Lewis' artery vanished, delaying the start of the inquest an additional six months.
The inquest into the cause of Ms. Lewis' death finally began in April 2002. The coroner's jury was charged not with assigning blame, but determining whether Dr. Emanuele's adjustment played a role in the death, and was given the option of five possible findings: homicide, suicide, accident, natural causes, and undetermined.
The position of the chiropractic profession was that Ms. Lewis died of natural causes, exacerbated by her poor overall health - being overweight, a heavy smoker and drinker, and suffering from high blood pressure - all of which put her at increased risk for stroke At the trial, several medical experts testified that Ms. Lewis' stroke was caused not by the chiropractic adjustment, but by advanced end-stage atherosclerosis that, in the words of Dr. Harker Rhodes, a neuropathologist at Dartmouth University Medical School, had "virtually completely destroyed" her left intracranial vertebral artery and blocked 70 percent of the right vertebral artery intracranially. Dr. Rhodes also stated "it was simply a coincidence" that Ms. Lewis received a neck adjustment a few days prior to her stroke.
Witnesses called by the coroner's office and evidence presented at the inquest provided differing testimony. One letter, signed by dozens of neurologists, stated that blood vessels such as the vertebral artery can tear if a person's neck is rotated improperly. Other witnesses testified that Dr. Emanuele's adjustment was "the probable source of injury" to Ms. Lewis, and that there was only minimal to moderate atherosclerosis in her vertebral arteries.
In addition to ruling Ms. Lewis' death an accident, the coroner's jury made 17 recommendations, including:
- That the Ministry of Health work with the Canadian Chiropractic Association (CCA) and the Canadian Memorial Chiropractic College (CMCC) to provide funding for a study to assess the relationship between high-neck manipulation and stroke/injury and/or serious complications.
- That practitioners obtain written, informed consent from their patients prior to performing high neck manipulation, and that they provide patients with an information sheet outlining the possible risks associated with neck manipulation.
- That the Ontario Ministry of Health consider creating an internal database, into which chiropractors, medical doctors, hospitals, physiotherapists, the coroner's office, and other health practitioners would report all cervical manipulations. A separate section of the database would document adverse events related to the manipulations.
- That a standard practice of record-keeping be established, whereby chiropractors would report the type and specific location of any manipulation performed on a patient, along with the type of technique used to perform the manipulation.
- That after receiving a neck manipulation, patients remain in the practitioner's care for "an appropriate amount of time" prior to leaving, so that they can inform the practitioner of any abnormalities or disturbances.
- That the Clinical Guidelines for Chiropractic Practice in Canada be upgraded every two years to keep practicing chiropractors up to date.
- That chiropractic schools, associations and regulatory agencies ensure all of their members maintain their skills by taking mandatory courses.
The decision in the Lewis case will allow the family to pursue its multimillion-dollar lawsuit against Dr. Emanuele.
Lawyers for the CCA and the CMCC expressed disappointment with the jury's verdict, saying it "represents a massive miscarriage of justice." In a statement to the media, attorney Tim Danson said the chiropractic profession would appeal the decision on the grounds that there was "a complete failure of justice in the conduct of the inquest." He also alleged that the coroner's office suppressed evidence that would have helped the chiropractic profession's position.
"The public should know, as should the jury, that two of the most distinguished and respected neuropathologists in the world, Dr. David Graham of Glasgow, Scotland, and Dr. Francesco Scaravilli, of London, England, were prohibited from testifying at the inquest [even though] the coroner was aware that as leading world authorities, their opinions commanded great respect, and would have carried considerable weight," said Mr. Danson. "... Dr. Graham and Dr. Scaravilli formed the opinion that this was the clearest case they have ever seen of a person dying as a result of natural causes, and any other explanation would be grossly speculative and unscientific."
This decision marked the first time in Ontario, and only the second instance in Canada, in which chiropractic manipulation of the neck was the subject of a coroner's inquest. The first inquest examined the death of Laurie Jean Mathiason, a 20-year-old woman from Saskatoon, Manitoba, who died in February 1998, three days after suffering a stroke while being adjusted. The jury in that inquest ruled that more research was needed to determine the risks and benefits of neck adjustment, and that the public be better informed.
Even before the jury ruled the death of Lana Lewis an accident, however, Canadian chiropractors were beginning to feel the backlash of the inquest. According to an article in the Toronto Globe and Mail, the Lewis inquest "subjected the chiropractic industry to terrible publicity," and some practitioners have reported a drop in billings and the number of patients treated by more than 20 percent.
But the battle does not end here, as Mr. Danson made clear in his comments to the media: "We have instructed our counsel to bring an Application for Judicial Review before a three judge panel of the Superior Court of Justice (Divisional Court) to quash the verdict on the grounds that it is perverse, and on the grounds that there has been a complete failure of justice in the conduct of the inquest."
- Bonnell G. Death of chiropractic patient in 1996 an accident, coroner's jury rules. Canadian Press, Jan. 16, 2004.
- Marshall E, Cuthbertson D. Chiropractic procedure blamed in death. CanWest News Service, Jan. 17, 2004.
- Chiropractic treatment needs safety review: jury. CBC News, Jan. 16, 2004.
- Coroner's inquest in Canada. Dynamic Chiropractic, Aug. 16, 2002. www.chiroweb.com/archives/20/17/05.html
- Information Bulletin from the Chiropractic Communications Working Group, Jan. 16, 2004.
- Katz denied standing in Canadian inquest ... again. Dynamic Chiropractic, Nov. 4, 2002. www.chiroweb.com/archives/20/23/13.html
- Lana Dale Lewis Inquest. Notable points of testimony & evidence to date. Submitted to Dynamic Chiropractic by Jonathan Bennett, Canadian Memorial Chiropractic College, Jan. 21, 2004.
- Legal counsel Tim Danson media statement. Submitted to Dynamic Chiropractic by Jonathan Bennett, Canadian Memorial Chiropractic College, Jan. 21, 2004.
- Toronto coroner disqualified Murray Katz, MD, from inquest. Dynamic Chiropractic, May 21, 2001. www.chiroweb.com/archives/19/11/18.html