Blunders brought to light at inquest
Coroner's office admits losing evidence in probe of chiropractic neck treatment
By GAY ABBATE
Saturday, May 4, 2002 Print Edition, Page A19
A heart destroyed. A coroner's file missing. Autopsy evidence discarded.
These are among a bizarre series of circumstances uncovered during an inquest into the death of a 45-year-old woman. They suggest that there may have been bungling by officials within the Toronto coroner's office.
In the two weeks since the inquest began looking into the possibility of a link between the stroke that Lana Dale Lewis suffered and a chiropractic neck adjustment, the jury has been bombarded with evidence of errors in the subsequent investigation.
The mother of three died on Sept. 12, 1996, 17 days after she sought chiropractic treatment for migraine headaches.
The jury has heard that:
Ms. Lewis's heart was removed for transplant and was destroyed several months later after the valves were donated;
Key sections of the vertebral neck arteries were removed for neurological examination in 1996 but were not examined until 2001;
About 100 slides of tissue examined during the autopsy went missing and had to be redone years later;
The coroner's file on the Lewis case cannot be found.
Because the blocks of tissue and arteries cut from the body for examination had been retained, new slide samples could easily be taken. The heart, however, was lost forever.
No one knows why it was not examined or who ordered it destroyed.
Lawyer Tim Danson has told the inquest that examining it could have shed light on whether it was diseased and caused the stroke. He represents the Canadian Chiropractic Association and the Canadian Memorial Chiropractic College in Toronto at the inquest.
The fact that the coroner's file was missing came to light only in the testimony of Dr. John Deck, one of two neuropathologists in the coroner's office who examined the body and tissue samples as part of the autopsy.
His recollection of having seen a document from the coroner's office containing information about Ms. Lewis's hypertension and other health problems prompted a search that proved futile.
Dr. Deck's own errors and conduct have been subjected to relentless questioning.
His first mistake, he has admitted, was assigning the task of cutting and analyzing samples to his young understudy, Dr. Michael Pollanen.
He submitted a report to Dr. Deck with his findings without having examined all the specimens. Dr. Deck reviewed the report and signed his name to it.
"I feel very bad we missed it," he told the inquest, adding that such an oversight would not have occurred had he cut the specimens himself.
Nevertheless, "I'm responsible for what happened," the 70-year-old retired doctor said.
The problems with the Lewis investigation go much deeper than missing evidence. Other blunders that have come to light during the inquest have given rise to allegations of bias and of conflict of interest high in the coroner's office.
In December of 1996, coroners Murray Naiberg and Robert Huxter, both since retired, invited three leading officers of chiropractic professional organizations and Dr. Deck to a meeting to discuss his preliminary autopsy findings. The fact that the Lewis family was not invited has raised questions about the ethics of the coroner's office meeting with only one side, not the normal procedure.
Dr. Deck has testified the meeting put some pressure on him, prompting him to soften his opinion. His conclusion: Neck manipulation might possibly have played a role.
Dr. Deck has been accused of bias against chiropractors because he wrote a letter outlining his opinion of the cause of death at the request of a lawyer representing the Lewis family in a multimillion-dollar lawsuit against the Toronto chiropractor who treated Ms. Lewis.
Letters, faxes and telephone calls between Dr. Deck and Dr. Murray Katz, a Montreal physician, have given chiropractors further ammunition to claim that Dr. Deck is against them.
Mr. Danson has called Dr. Katz the chiropractors' No. 1 enemy for his three decades of lobbying against neck manipulation.
More bizarre revelations are expected this coming week when Dr. Pollanen takes the stand to explain why he has changed his opinion about the cause of death.
In 1997, he was positive that neck manipulation caused the stroke.
He is expected to testify that plaque which broke off from her clogged arteries caused the fatal stroke.