# John Lawler Inquest

The John Lawler inquest refers to a coroner's inquest into the death of 80-year-old John Lawler, who died following a chiropractic treatment in York, England in August 2017. Lawler visited the clinic of York chiropractor Arleen Scholten in August 2017 seeking relief for back pain, but during a spinal manipulation session, he suffered severe complications that led to his hospitalization and eventual death the following day. Coroner Jonathan Heath led the inquest, examining whether Scholten’s actions contributed to Lawler’s death. Although the coroner acknowledged a link between the treatment and Lawler's death, Scholten was not found criminally negligent. The case led to a prevention of future deaths report by the Judiciary of England and Wales.

## Background

John Lawler, aged 80, visited Arleen Scholten’s chiropractic clinic in York on August 11, 2017, for relief from chronic back pain. During the session, Scholten performed spinal manipulations, which soon caused Lawler to experience serious medical complications. He was subsequently hospitalized and died the next day. The 2019 inquest investigated whether Scholten’s treatment was appropriate for Lawler’s condition and if it directly caused his death. Though the spinal manipulation was found to be a factor in Lawler's demise, Scholten was cleared of wrongdoing after the inquest.

## Incident and investigation

Following Lawler’s death, a coroner’s inquest was launched to determine whether Scholten’s treatment directly contributed to the fatal outcome. The inquest examined the appropriateness of the chiropractic procedures performed and whether they were executed in accordance with standard medical practices.
The coroner's report emphasized that Lawler's spine was more fragile than expected due to calcification, a condition common in older patients, which made his spine more prone to injury. The inquest also noted that no X-rays were taken before treatment, which may have revealed the severity of Lawler’s condition.

## Coroner's inquest

The inquest, held in 2019, examined whether Scholten's spinal manipulations were responsible for Lawler's death. The coroner, Jonathan Heath, heard testimony from experts who outlined the risks associated with high-velocity spinal manipulations, particularly in patients with conditions like Lawler's. Testimony from Lawler's widow detailed how he expressed discomfort during the treatment, including complaints of severe pain and numbness.
The coroner criticized the lack of pre-treatment imaging, which could have informed Scholten of Lawler's condition, and noted that Scholten’s handling of the emergency, including the misleading information given to paramedics, was concerning. However, the inquest concluded that Lawler’s calcified spine contributed significantly to the severity of the injury and that there was no intent of wrongdoing on Scholten’s part.

## Verdict and outcome

After reviewing the evidence, the coroner concluded that Lawler’s death was due to complications from the chiropractic treatment but did not attribute criminal negligence to Arleen Scholten. The inquest resulted in a narrative verdict, meaning no charges were brought against her. However, the case prompted calls for stricter regulations within the chiropractic profession, including the recommendation that chiropractors conduct pre-treatment imaging, such as X-rays, on patients with similar medical histories.

## Aftermath and impact

The inquest into John Lawler’s death had a significant impact on the chiropractic profession and public awareness of the risks associated with spinal manipulations. It led to renewed discussions on the importance of thorough patient assessments, particularly for elderly patients with pre-existing spinal conditions. Professional chiropractic associations emphasized the necessity for clearer communication between chiropractors and their patients, ensuring that all potential risks are fully understood.