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The GCC recently received a Regulation 28 (Prevent Future Deaths) report from a coroner. This followed an inquest into the tragic death of 29-year-old Joanna Kowalczyk on 16 October 2021.

The key focus of an inquest is how a person came by their death, and a Regulation 28 report allows a coroner to raise concerns where they consider that more may be done to prevent future similar deaths.

Such requests to the GCC are rare and the inquest gathered some media interest. Our immediate response was published on our website (though not all media outlets chose to contact us before reporting the story) but we understand the case may also have raised some concerns for chiropractors and their patients.

The ongoing GCC Investigation

The chiropractor involved is subject to a GCC investigation, which was paused to allow for the coronial process. This is standard procedure.

It is not appropriate for us to comment further as it could prejudice proceedings. It is inappropriate and unprofessional for chiropractors to speculate publicly on the details of the case, or the identity of the individual involved.

All matters brought to the attention of the GCC are risk assessed and are considered by an Investigating Committee. More about the investigation process.

The Regulation 28 report

In her report, the Coroner has asked the GCC to consider the following concern.

(I am) “concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken.”

We will give full and careful consideration to her concern. Given the clinical matters involved, we are seeking expertise (from across the profession, and beyond) to consider the impact of such a step - including on the care and safety of all patients. The Registrar will be writing to the coroner in the next week to set out how her concerns will be considered, and the expected timing of that work.

We have been in contact with leaders from across the profession and are grateful to them all for their support of our proposed approach.