The Jury’s Verdict
By John Reggars

“A Massive Miscarriage of Justice - A Stunning and Perverse Result”. So says Tim Danson, the lawyer representing Dr. Philip Emanuele the chiropractor implicated in the 1996 death of Lana Lewis. Not so says the family of Mrs. Lewis who got the verdict they were hoping for and then promptly filed a $12 million lawsuit against Dr. Emanuele.

After nearly two years, the jury in the Coroners Inquest into Mrs. Lewis’ death, was charged with determining the cause of her death. They were capable of delivering three verdicts - accidental, natural or undetermined. A finding of death by “accident” would indicate that Mrs. Lewis’ death was caused inadvertently without foresight or expectation, while “natural” would indicate death from disease or a complication from disease. The jury could also have delivered a verdict of “undetermined” which would indicate that there was inadequate evidence to draw firm conclusions or that the evidence points to two or more causations.

To refresh your memory, Mrs. Lewis, a 45 year old woman of Toronto, Ontario, Canada, was admitted to hospital suffering from a stroke, six days after undergoing chiropractic cervical manipulation administered by Dr. Emanuele. Eleven days after this stroke she suffered a further stroke and died on 12th September 1996. The case as I described in the September issue of COCA News, resembled a good plot for a movie with all the characteristics of a murder mystery. www.coca.com.au/newsletter/2002/sep0203a.htm.

Lewis was known to be a heavy smoker and drinker and suffered from several relevant health problems including hypertension, high blood cholesterol, a history of vascular disease, obesity and migraine headaches and was described by some of the expert witnesses to be a “walking time bomb” for stroke. The lawyers for Dr. Emanuele and associated Canadian Chiropractic organizations argued that Mrs. Lewis’ death was due to natural causes and it was a mere coincidence that she attended Dr. Emanuele six days before her first stroke. At autopsy, an expert witness found Mrs Lewis to have severe atherosclerosis both intra-cranially and extra-cranially, with the left vertebral artery being completely blocked and containing a thrombus, while the right vertebral artery being severely to moderately occluded.

The arguments for both sides centred on several factors. However, the expert scientific evidence on these points was conflicting and sometimes contradictory. Did Mrs. Lewis develop neck pain and dizziness in the week prior to her hospital admission, and after her cervical manipulation. Or was it just prior to her hospital admission? If she experienced these symptoms either immediately, or a short time after her neck adjustment, then it is possible she was exhibiting signs of a vertebral artery dissection caused by the manipulation. If she was exhibiting signs of a vertebral artery dissection later, the onset was most likely unrelated to her manipulation. Of all the expert witnesses called to testify on the histopathogical examination of Mrs. Lewis’ vertebral arteries, none could identify a dissection. However notwithstanding this fact, several experts testified that she died from the complications associated with dissection. The point of the presence of an undetected dissection was a key point in the case put forward by Mrs. Lewis’ legal team to implicate the chiropractic adjustment as the cause of her stroke. A point also made by the lawyers for the chiropractic profession was that Mrs. Lewis received her adjustment to the right side of the neck yet it was the left vertebral artery that was found to contain the fatal thrombus.

Did she have advanced atherosclerosis or mild atherosclerosis? Again there were differing opinions from the experts. With mild plaquing the evidence would tend to support the dissection theory but with moderate to severe plaquing death was most likely due to natural causes.

My rough calculations estimate that there were more than 20 expert witness including, amongst others, seven pathologists, epidemiologist David Sackett, neurologists, radiologists, and expert chiropractic witnesses. The experts were divided into three camps - a trauma group, a natural causes group and an “I don’t know group. The two pathologists who originally conducted the autopsy not only had different opinions as to the cause of death but also changed their own opinion during the inquest. Dr. Deck started in the trauma group, but later testified that he didn’t know the cause of death. Dr. Pollanen also started in the trauma camp and like Dr. Deck jumped over to the I don’t know camp and finally to the natural causes camp. Intertwined within some of the expert testimony, and lingering in the shadows, was “The Black Hat” Murray Katz, the noted anti-chiropractic crusader. Dr. Katz took a leading role in the early scenes of this inquest and was mentioned in my earlier article on this case, along with neurologist John Norris, who with some colleagues is urging for a ban on cervical manipulation.

I find it difficult to get my head around the fact that 20 or so expert witnesses could have such differing opinions, often with extreme polarization. So much for expert testimony? It is understandable that a jury of lay persons would be somewhat confused when confronted with such conflicting scientific evidence by so called experts. Even counsel for the Coroner, Mr. O’Mara, in his summation told the jury that experts’ views on this case could be characterized as polar opposites and he found it troubling that so many experts can look at the same material and see different things and arrive at different conclusions. Moreover, he found it even more troubling that experts can look at the same material, see the same things and arrive at different conclusions.

From my reading of the evidence a finding of death by natural causes, or undetermined would have been an appropriate verdict for the jury to bring down. However, I have relied heavily on publications by the Canadian Chiropractic Communications Group, to form my opinions and therefore, the possibility of bias is ever present. Nonetheless, if you think this couldn’t happen in Australia you are sadly mistaken.

It appears that the only good thing to come out of this inquest was that the jury made 17 recommendations to the government, the medical profession and the chiropractic profession, in the hope that similar deaths can be prevented in the future. Among these recommendations were:

• That the government fund a Level III retrospective case control study to investigate the relationship between cervical manipulation and stroke or other serious complication.
• That all practitioners using high cervical manipulation obtain written informed consent, as well as provide an information sheet describing to patients the signs and symptoms of stroke and, in such circumstances, for them to seek further advice from their practitioner or emergency department.
• That due to the lack of validity and reliability of pre-manipulative provocative vascular testing, these tests should not be performed and that teaching institutions educate their students on the lack of benefit from performing these tests.
• That a committee be established to foster better dialogue between the chiropractic and medical professions.
• That as a standard of practice a practitioner’s record keeping should include the type and specific location of the manipulation and the type of manipulation.
• That a data base be established to report cervical manipulation and to record all adverse events associated with cervical manipulation.

A number of other recommendations were made regarding the conduct of the Coroners Office, clinical guidelines etc.

This is a problem the chiropractic and osteopathic professions of Australia cannot ignore. Just imagine this case happening here and that one of the current affairs programs happens to take the view it was the manipulation that caused the death. Just imagine what that would do to patient loads, particularly if like the Lewis case it went for nearly two years. It’s a problem that won’t go away in a hurry and the chances are, that it will get bigger and bigger. Even if manipulation is not the cause of some strokes the onus is on us to prove it. Counsel for Dr. Emanuele has appealed the decision in an attempt to have the verdict overturned but the damage is already done, in more ways than one.