Joanna Kowalczyk

Private and Confidential 

Ms Leila Benyounes 

Assistant Coroner for Gateshead and South Tyneside 
Coroner Office,  
Town Hall and Civic Offices 
Westoe Road, South Shields 
Tyne and Wear  
NE33 2RL 

27 November 2025 

Dear Ms Benyounes, 

Inquest: Joanna Daria Kowalczyk 

At the conclusion of the inquest on 22 January 2025 investigating Joanna’s sad death you 
issued a Regulation 28 (prevention of future deaths) report to, amongst others, the General 
Chiropractic Council (GCC). 

I wrote to you in March explaining that we would be establishing an Expert Group, 
comprised of members from within and outside of the profession, to consider your findings 
and any further lessons from the circumstances of her death. 

This letter is to update you on the findings of the Expert Group, and the Action Plan that the 
GCC and representatives of the chiropractic profession have agreed to take to mitigate 
against a comparable incident occurring in the future. 

Fitness to Practice Investigation 

Before I share the considerations that led to the Action Plan, I should inform you that our 
investigation into the actions and fitness to practice (FTP) of the individual chiropractor 
involved in Joanna’s care continues. The investigation has been kept entirely separate from 
the work of the Expert Group, so that each does not impede the other. However, should 
further lessons come to light from the FTP proceedings, these will also be acted on. 

The Expert Group Action Plan 

I have enclosed a copy of the Expert Group’s Action Plan. The group settled on four themes 
and sought practical solutions for chiropractors to incorporate into their daily practice. The 
Action Plan is purposefully heavy on activity, and light on reasoning, but I have expanded on 
their deliberations for your information below: 

Park House, 186 Kennington Park House, London, SE11 4BT   Tel: 020 7713 5155   enquiries@gcc-uk.org   www.gcc-uk.org 
Os byddwch yn dewis ysgrifennu atom yn Gymraeg, byddwn yn ymateb yn Gymraeg. Ni fydd gohebu yn Gymraeg yn arwain at oedi. Fodd bynnag, nodwch nad oes yr un 
o'n staff yn siarad Cymraeg ar hyn o bryd. 

 
 
 
 
 
 
 
 
 
 Theme 1 – accessing medical records. 

The Expert Group specifically considered your direction to: 

“ensure consideration to obtaining medical records should always be given before assessment, 
particularly where recent medical treatment or investigations have been undertaken”. 

While “considering” obtaining medical records was felt to be standard practice in the 
profession, and reflected in standard D1 of the new Code of Professional Practice (2026), it 
was recognised that there were systemic issues (both real and perceived) – particularly for 
those in private practice seeking NHS records – which could prevent or dissuade a 
chiropractor from “obtaining” medical records. These issues could lead to a habitual 
“downplaying” of the relevance of the medical records when taking a thorough case history. 

The actions in output 1 are designed to improve chiropractor understanding of the current 
best practice when accessing medical records, and using those records in the creation of a 
thorough case history. 

Theme 2 – Understanding and discussions of clinical risk 

The Expert Group was concerned that chiropractors and patients may both shy away from 
conversations around rare, but catastrophic, risks. The group recognised that if a patient is 
not informed of the risks of a particular type of care, then they are not able to provide valid 
consent, or fully partake in shared decision-making. 

The actions in output 2 are designed to support both chiropractors and patients in better 
communicating and understanding these risks, so that every individual can make decisions 
on the level of risk that they are prepared to accept. 

Theme 3 – Identifying the risk factors for cervical arterial stroke 

The Expert Group set aside questions of causality in favour of a “precautionary principle” 
position that, as health care providers, chiropractors will encounter patients at risk of stroke. 
They identified that there was inconsistent understanding of stroke, the symptoms and the 
risk factors for patients in the profession. 

The actions in output 3 are intended to challenge every member of the profession to reflect 
on their knowledge of stroke, and to direct them to reputable information to further educate 
themselves. 

Theme 4 – Responding to a stroke in progress 

The Expert Group noted that, while there is a low probability of any individual encountering 
a patient suffering a stroke in progress, it is inevitable that someone within the profession 
will face a similar situation.  

The actions in output 4 seek to develop best practice across the profession to give patients 
requiring urgent care the best chance of survival. 

Park House, 186 Kennington Park House, London, SE11 4BT   Tel: 020 7713 5155   enquiries@gcc-uk.org   www.gcc-uk.org 
Os byddwch yn dewis ysgrifennu atom yn Gymraeg, byddwn yn ymateb yn Gymraeg. Ni fydd gohebu yn Gymraeg yn arwain at oedi. Fodd bynnag, nodwch nad oes yr un 
o'n staff yn siarad Cymraeg ar hyn o bryd. 

 
 
 
 
 The wider context within the chiropractic profession. 

In 2024, the GCC reviewed and updated the standards of proficiency for chiropractors. The 
new standards were published ahead of the inquest (31 December 2024) but must “sit” for a 
year before they come into effect (on the 1 January 2026). References to the Code of 
Professional Practice in this letter, and in the Action Plan, refer to this new document (which 
was not in place at the time of Joanna’s death). However, we do not believe that the 
changes to the Code would have made a material difference to the expectations of the 
chiropractor in this case. 

Each year the General Chiropractic Council requires every registrant to complete a focused 
reflection as part of their continuous professional development (CPD) record. Our 
experience is that the focused reflection topics create an impact across the providers of 
CPD events. The focus for the current CPD year (September 2025 to August 2026) is on 
safety and quality in clinical practice – and this will provide additional context for the activity 
within the Action Plan. 

Finally, I have been heartened by the response of the profession’s leadership to Joanna’s 
death. Separate to their support of the Expert Group, and the resulting Action Plan, the 
British Chiropractic Association held webinars to refresh the knowledge of their members on 
the symptoms and treatment of stroke. Furthermore, the Royal College of Chiropractors 
initiated work to review their emergency referral form (used by chiropractors to share 
immediate concerns with frontline emergency healthcare professionals). Promoting the 
adoption of this form is one of the activities in the fourth theme. 

Throughout this process, we have kept Joanna Kowalcyzk foremost in our minds. 

I do not intend to update you further on our progress, but hope that we have demonstrated 
the resolve of the GCC, and the wider profession, to learn from the circumstances of her 
death and provide safer care for chiropractic patients in the future 

Your sincerely. 

CEO and Registrar. 

Park House, 186 Kennington Park House, London, SE11 4BT   Tel: 020 7713 5155   enquiries@gcc-uk.org   www.gcc-uk.org 
Os byddwch yn dewis ysgrifennu atom yn Gymraeg, byddwn yn ymateb yn Gymraeg. Ni fydd gohebu yn Gymraeg yn arwain at oedi. Fodd bynnag, nodwch nad oes yr un 
o'n staff yn siarad Cymraeg ar hyn o bryd.

Ms Leila Benyounes 
Assistant Coroner for Gateshead and South Tyneside 
Coroner Office, Town Hall and Civic Offices 
Westoe Road, South Shields 
Tyne and Wear  
NE33 2RL 

12 March 2024 

Dear Ms Benyounes, 

Inquest: Joanna Daria Kowalczyk 

At the conclusion of the inquest on 22 January 2025 investigating Joanna’s sad 
death you issued a report under paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013.  

Your report was issued to, amongst others, the General Chiropractic Council (GCC) 
indicating that we respond by 25 April 2025. This is our response.  

The GCC was an interested party at the Inquest. Our investigation into the actions of 
the chiropractor involved in the treatment of Joanna are ongoing.  

We acknowledge the Regulation 28 report and that we consider [our role in ensuring] 
that ‘consideration to obtaining medical records should always be given before 
assessment, particularly where recent medical treatment or investigations has been 
undertaken.’  

It is our intention to carefully consider your findings and ensure that any action that 
can be taken to prevent a further death or harm to patients in similar circumstances 
will be.  

To support us in doing so, we have established an expert group, comprised of 
experts from within and outside of the profession to undertake a review. The 
membership of the group together with its draft terms of reference and expected 
timeline is enclosed.  

We expect the work to take place between now and the summer of 2025, with the 
final report and recommendations being considered by the General Chiropractic 
Council at its meeting on 1 October 2025. Progress will also be reported to Council 
in public at its meetings on 19 March and 18 June 2025. 

Park House, 186 Kennington Park Road, London SE11 4BT     Tel 020 7713 5155      enquiries@gcc-uk.org      www.gcc-uk.org 

 
 
 
 
 
 
 
 I am happy to provide further information to you, colleagues or other parties.  

Yours sincerely 

Chief Executive and Registrar 

2

Strictly Private and Confidential  
Miss Leila Benyounes 
His Majesty's Assistant Coroner for 
Gateshead and South Tyneside 
Coroner Office,  
Town Hall and Civic Offices,  
Westoe Road, South Shields,  
Tyne and Wear,  
NE33 2RL 

Date: 16th April 2025   

Dear Miss Benyounes, 

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Tel :  0191 430 2000 
www.neas.nhs.uk 

Ref: 

Inquest into the death of Joanna Kowalczyk 

Regulation 28 – Report to prevent future deaths  

I am writing in my role as Chief Executive of North East Ambulance Service NHS Foundation 
Trust ("NEAS") and in response to the Regulation 28 report for the prevention of future deaths 
dated 21 January 2025 as issued by you following the inquest into the tragic death of Joanna 
Kowalczyk.  I am sorry that you have had to raise concerns with NEAS following the inquest 
and  would  like  to  take  this  opportunity  to  pass  on  my  sincere  condolences  to  the  family  of 
Joanna. 

I  am aware that the report  was also  issued  to  the  General Chiropractic  Council.  We  will not 
address this specific concern and simply respond to that specifically related to NEAS. 

I will address the NEAS point you have raised in your matters of concern below: - 

1.  The  evidence  from  the  attending  paramedic  was  that  she  was  not  aware  that 
symptoms of a stroke can stop after a short time as clearly set out on NHS website 
and guidance, and that this was not part of her training. This was directly contrary to 
the Head of Operations’ evidence that this was part of both paramedic training and 
annual  continuing  professional development.  This  was  a  concerning  feature  given 
the  accepted  evidence  of  the  time  critical  period  to  treat  patients  with  symptoms 
potentially indicative of stroke. 

In respect to the NHS website this contains information for the public in relation to stroke which 
I believe is what the family pointed out. The information is however directed towards the public 
in  so  far  that  the  symptoms  section  contains  the  statement  ‘symptoms  of  a  stroke  can 
sometimes  stop  after  a  short  time,  so  you  may  think  you're  OK.  Even  if  this  happens,  get 
medical help straight away’. The following link will direct you onto the information which I believe 
is referenced https://www.nhs.uk/conditions/stroke/. This is not intended to provide guidance to 
health professionals and directs the public to seek medical help which is what happened in this 
case.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601). 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I am aware that  evidence from one of the attending Paramedics led you to believe  that they 
were not trained to recognise that symptoms of a stroke could cease after a period of time. This 
was despite the Head of Operations confirming in evidence that firstly he thought the Paramedic 
had not understood the question. The evidence provided by the Head of Operations described 
how Paramedics were trained and that secondly, he would ensure that following the inquest he 
would feed this back to the Paramedic and send a wider update to the Paramedic cohort at the 
Trust reminding them of the potential for stroke symptoms to dissipate over time. Further to the 
conclusion of the inquest the Paramedic took it upon themselves to write a detailed Continual 
Professional  Development  (CPD)  piece  to  demonstrate  their  understanding  of  Stroke  and 
Transient Ischemic Attack (TIA).  

In respect to the education and training of Paramedics I have set out the education journey and 
the ongoing CPD undertaken as a registered healthcare professional.  

Academic Education via University 

During  Paramedic  training  (this  is  the  3-year  BSc  or  the  older  2-year  paramedic  degrees), 
Stroke/  TIA  and  neurological  conditions  are  all  covered  and  how  to  recognise  signs  and 
symptoms. During  the  sessions  covering  Stroke/TIA,  students  are  informed  and  taught  that 
symptoms  may  have  resolved  on  arrival  but  anyone  who  has  displayed  symptoms  of  a 
Stroke/TIA  which  have  resolved  will  not  be  left  on  scene  but  referred  to  another  healthcare 
professional.  This would usually mean conveyance to the local hospital and/or the stroke unit 
should be contacted.  Students are taught that symptoms of a stroke that have ‘resolved’ could 
be a red flag/ predisposing factor to a further stroke. 

1.  An example of a university course is Teesside university and the internal NEAS students 
(BSc level), year one includes a neurological module which talks about each condition 
and then how to assess symptoms which includes observations, pupil response, FAST 
(face,  arms,  speech,  time),  AcVPU  (alert,  new  confusion,  voice,  pain,  unresponsive)  
consciousness and GCS (glasgow coma scale), and goes into further detail such as the 
cranial  nerve assessment.   All  of  these  points  are discussed  including  how to  identify 
any abnormalities.  

2.  Year  two  provides  further  in  depth  education/training  in  respect  to  the  neurological 
system, symptoms and assessment. An example of learning is a journal article ‘a survey 
of UK Paramedics’ views about stroke training, current practice and the identification of 
stroke mimics’ by Dr Graham McClelland et al.  

3.  Year three education/training revisits the elements of the previous years, including signs 
and  symptoms. This  does  not  include  additional  new  information  and  acts  as  a 
continuation of previous learning by students to ensure it is embedded learning. 

Initial Onboarding Course 

Stroke and Transient Ischaemic Attack (TIA) is covered in education and training for Ambulance 
Care Assistants (ACA), Ambulance Support Practitioners (ASP) and Paramedics.  Training for 
ACA/ASP  include  how  to  recognise  signs  and  symptoms  Stroke  and  Transient  Ischaemic 
Attack (TIA).   Newly  Qualified  Paramedics  (NQP)  and  Qualified  Paramedics  courses  do  not 
revisit  their  previous  education  and  training,  however  training  covers  stroke  pathways  and 
bypass care bundles. The term ‘care bundles’ relates to a collection of interventions that may 
be applied to the management of a particular condition i.e. stroke pathway.  These care bundles  
are  also  covered  in  the  Electronic  Patient  Care  Record  (EPCR)  training  alongside  how  to 
complete accurate documentation.  

 
 
 
 
 
 
 
 
  
 
 Newly Qualified Paramedic (NQP) Portfolio (band 5)  

After graduation, Newly Qualified Paramedics (NQPs) have up to two years to complete their 
Newly Qualified Paramedics portfolio.  This is nationally recognised process and is completed 
by all Newly Qualified Paramedics.  Part of the portfolio is to document progression, including 
meetings  with  Mentors  and  identifying  areas  of  development.   During  these  sessions 
discussions include patient assessments and clinical decision-making.  The process does not 
include  anything  specific  for  ‘neurological’,  however  throughout  process  of  completing  the 
portfolio  evidence  is  collated  to  cover  physical  examinations,  risk  assessments,  appropriate 
decision  making,  the  use  of  clinical  judgment  to  select  most  likely  diagnosis  in  relation  to 
evidence gathered, and many other areas where evidence needs to be supplied of when they 
have carried out that point.   

During this stage of their career Newly Qualified Paramedics cannot discharge on scene, with 
a  requirement  that  they  ensure  input  of  a  senior  clinician  prior  to  discharging  a  patient  at 
scene.  As part of their continued learning and reflective practice Newly Qualified Paramedics 
maintain ‘clinical learning diaries’ logging specific cases they have attended, including the likes 
of suspected Stroke and Transient Ischaemic Attack (TIA). 

Statutory and Mandatory Training  

On  an  annual  basis  ambulance  staff  undergo statutory  and  mandatory  training.  The  annual 
training is developed with various specialist departments agreeing what should be included and 
co-designing  the  packages  prior  to  commencing  the  training  programme.  This  approach 
includes any identified learning throughout the previous year and/or any changes in practice 
coming through external recommendations and/or requirements. Stroke training was included 
in the annual training in 2018/2019 and covered stroke statistics, definitions, risk factors, signs 
and  symptoms,  stroke  mimics,  assessment,  treatment,  current  NEAS  performance  and 
potential areas for improvement. 

The 2022/2023 statutory and mandatory training included Stroke and was delivered via a video/ 
e-learning  presentation  developed  by  Dr  Graham  McClelland,  this  included  a  focus  on  his 
Stroke  research  undertaken  at  that  time.   The  training  included  a  refresher  on  pre-hospital 
stroke care, recommendations, Paramedic Acute Stroke Treatment Assessment (PASTA) trial, 
thrombectomy,  time  =  brain,  FAST  (face,  arms,  speech,  time),  pre-alerts,  dispatch  criteria, 
statistics,  Electrocardiogram  (ECG),  Intravenous  (IV)  cannulation  and  not  to  delay  on  scene 
time. 

Joint Royal Colleges Ambulance Liaison Committee (JRCALC) 

It may be helpful to explain the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) 
guidance.  The  JRCALC  guidelines  have  evolved  from  many  locally  derived  protocols  to 
systematically developed national clinical practice guidelines based on current best evidence. 
The ongoing continuous updates are supported via the JRCALC Guideline Development Group 
(JRCALC-GDG),  have  over  the  years  been  responsible  for  developing  and  reviewing  the 
national  clinical  practice  guidelines  for  NHS  Paramedics.  JRCALC  guidelines  are  also  an 
important part of clinical risk management and ensure uniformity in the delivery of high-quality 
patient care. As such, they form the basis for UK Paramedic training and education. JRCALC 
combines expert advice with practical guidance to help Paramedics in their challenging roles 
and supports them in providing patient care.  

 
 
 
 
  
 
 
  
 
 
 
 
 
 The guidelines cover an extensive range of topics, from resuscitation, medical emergencies, 
trauma, obstetrics and medicines to major incidents and staff wellbeing. Stroke and Transient 
Ischaemic  Attack  (TIA)  have  a  full  section  under  JRCALC  too  which  discusses  symptoms, 
treatment, time critical factors.  It states, ‘patients with TIA may be at high risk of stroke and 
require  urgent  specialist  assessment,  and  local  pathways  should  be  followed’.    JRCALC  is 
broken down into the following headings: introduction, pathophysiology, incidents, severity and 
outcome, assessment and management, audit information and key points.   

In addition to education and training all NEAS Paramedics are given access to the JRCALC 
guidelines through individual licenses for the JRCALC Plus app. JRCALC Plus allows individual 
ambulance services to combine the national guidelines with their regional information, this is 
achieved via individual login details linking with the specific Ambulance Trust. The app contains 
the following which is utilised by NEAS: 

▪  Complete JRCALC Guidelines 
▪  Regional and local guidance specific to NEAS 
▪  Clinical Notices/Bulletins  
▪  Medications information including patient group directives  
▪  All updates and alerts are published in real time as new guidance is issued 
▪  The app works offline and is therefore accessible to our teams 

Emergency Ambulance crews can access the JRCALC Plus app via iPads which are now being 
transitioned to   personal issue, with the rollout of personal issue devices commencing in August 
2024, prior to this date the iPad (or previous electronic device) was part of the standard vehicle 
equipment. In addition, the clinicians have the option for the App to be downloaded on other 
devices such as personal smart phones if they so choose so. This allows clinicians to access 
the guidelines whilst at the patient side and/or when travelling to the case. 

Stroke  and  Transient  Ischaemic  Attack (TIA)  have  a  full  section  under  JRCALC  too  which 
discusses symptoms, treatment, time critical factors.  It states, ‘patients with TIA may be at high 
risk  of  stroke  and  require  urgent  specialist  assessment,  and  local  pathways  should  be 
followed’.   JRCALC  is  broken  down  into  the  following  headings:  intro,  pathophysiology, 
incidents,  severity  and  outcome,  assessment  and  management,  audit  information  and  Key 
points.   

In addition to education and training provided to our staff, we have recently  strengthened our 
Senior Clinical Leadership team. Under the leadership of our Director and Deputy Director of 
Paramedicine,  we  have  appointed  three  Consultant  Paramedics  and  a  Head  of  Clinical 
Development  and  Effectiveness.  The  team  are  working  closely  with  internal  and  external 
colleagues to develop clinical and professional leadership of our clinical workforce, developing 
our capabilities, standards and opportunities for development across our system. This includes 
a  strong  link  into  the  ongoing  education  and  training  of  our  clinical  workforce,  ultimately 
complimenting the details I set our previously alongside ongoing CPD undertaken as registered 
healthcare professionals. 

I trust that this response provides you and the family with the  re-assurance that, as indicated 
by the Trust’s Head of Operations in live evidence at the inquest, staff are and continue to be 
educated and trained in respect to stroke and neurological conditions including the potential 
that symptoms of a stroke can dissipate.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 If it would be helpful, we would gladly arrange a visit to our  internal Education Centre so you 
can see our facilities and receive an overview of the education provided to our staff.  May I once 
again  pass  on  my  sincere  condolences  to  the  family  of  Joanna.  If  we  can  be  of  any  further 
assistance then please do not hesitate to contact 
, Head of Regulatory Services 
via email at 

or telephone 

.  

Yours Sincerely 

Chief Executive

Your Ref: |

19 March 2025

Ms Leila Benyounes
HM Assistant Coroner for Gateshead & South Tyneside

By Email only

Dear Ma'am,
Joanna Daria Kowalczyk Inquest: Regulation 28 Report to Prevent Future Deaths Response

| write to formally respond to your Prevention of Future Deaths (PFD) Report, dated 22 January 2025,
following the inquest into the sad death of Ms Joanna Kowalezyk.

Your concern was as follows:

"2. The evidence on behalf of the treating chiropractor was that he did not consider it necessary to
request GP records or hospital records, before assessment or treatment despite being informed about
the Deceased’s recent hospital attendance, investigation which was recommended, and her discharge
against medical advice. Even in the updated consent form | have been provided with, which was
designed by the British Chiropractic Association, there is no prompt or question designed for the
chiropractor to ask to consider obtaining medical records before assessment or treatment, and when
this may be appropriate, and the only reference to medical records is a consent to communicate as
deemed necessary for the treatment, and for a report to be sent to the GP after treatment. | am
concerned that consideration to obtaining medical records should always be given before assessment,
particularly where recent medical treatment or investigations has been undertaken."

As a Chiropractor registered with the General Chiropractic Council (GCC), | ensure that | meet the
training standards and competencies set out GCC's Code of Practice, particularly, as relevant in this
case, in the context of Principle C, providing a good standard of clinical care and practice: C1 - Obtain
and document the case history of each patient, using suitable methods to draw out the necessary
information.

| will continue to follow the rules and guidance issued by my regulator, and | look forward to receiving
any updated or additional guidance put in place by the GCC in response to your Regulation 28 report.

If you require any further information, please let me know.

Yours faithfully,