Fitness to Practise Learnings: reassessment of care plans, and misleading claims of chiropractic subluxation

Background

The conduct related to two separate allegations. After qualifying in the UK, the chiropractor had chosen to register (and remain registered) with the GCC despite practising and living abroad.

Allegation 1 - failing to reassess the plan of care:

In late November 2021, the chiropractor assessed a patient with symptoms of dizziness, vertigo, nausea and neck pain. They proposed a plan of twenty-four treatment sessions over 3 or 4 months, with a planned reassessment at visits 12 and 24.

The PCC heard that, after the first and second treatment sessions (in December), the patient reported new and worsening symptoms including severe tinnitus, vertigo, dizziness, nausea, coughing and vomiting.

Despite these new clinical signs, the chiropractor did not undertake or record a reassessment of the patient until the scheduled “visit 12” reassessment (at the end of January - eight appointments after the report of tinnitus).

In March 2022, the patient told the chiropractor he had been diagnosed with Ménière’s disease by a medical professional. Ménière’s disease is a rare inner ear condition that affects balance and hearing.

Despite this new clinical diagnosis, the chiropractor again failed to update or vary the plan of care – only carrying out a second reassessment (as originally planned) during the 24th (and final) visit in late May.

The PCC also heard criticism from an expert witness of the quality of the reassessments performed by the chiropractor, namely:

• Different tests were used at diagnosis and reassessment - making measuring progress relative to the benchmark set at the first appointment impossible.
• There was no subsequent testing of blood pressure, despite the chiropractor making a note during the initial diagnosis visit to check it as it was high.
• There was no testing of the cranial nerves.

The PCC found that, even following the reassessment in late January, the chiropractor did not make any modification of substance to his treatment plan but carried on as before with the original plan. The chiropractor took insufficient account of what his patient told him and showed an over-reliance on thermographic scans taken at each appointment.

Allegation 2 - making misleading claims.

The PCC also considered a second allegation that the chiropractor had caused or allowed inappropriate and/or misleading information to be produced and/or communicated.

This related to three separate pieces of material:

• a series of three videos claiming that chiropractic care was effective in treating Ménière’s disease.
• a leaflet entitled “learn more about your nerve system” that claimed deterioration of health and conditions such as stomach, immunity and disc issues were caused by compression of the spinal cord by a so-called chiropractic subluxation.
• a witness statement from the patient describing how the chiropractor had explained his symptoms in terms of: “a blockage between my brain and body. By removing this blockage by making adjustments on my neck the brain would be able to send signals to my body more effectively, thus causing my health to improve and symptoms to alleviate”.

The PCC found that the claims in the videos regarding Ménière’s disease were misleading, inappropriate and not supported by robust scientific evidence. However, they did not consider that the videos were evidence of a wider pattern of producing inappropriate and misleading information. For this reason they found the behaviour was below, but not far below, the standards expected of a registrant.

The PCC considered that the claims made in the leaflet, and reported by the patient in the witness statement, were also misleading, inappropriate and not supported by robust scientific evidence. Crucially, however, the PCC considered that these statements were made more inappropriate and misleading by the fact that the chiropractor should have been aware that the GCC had issued specific guidance on this question.

The Committee found that the inappropriate and misleading claims in relation to subluxation fell far short of the standard expected of registrants and had the potential to undermine public confidence in the chiropractic profession.

PCC Findings

Allegation 1 - failing to reassess the plan of care:

In relation to the first allegation, the PCC found the chiropractor was guilty of unacceptable professional conduct because he failed to provide an adequate standard of care. He had:

• failed to update or vary the plan of care given to a patient despite there being no reported or measurable progress.
• failed to undertake or record a new assessment despite the patient highlighting new clinical signs to the chiropractor.

This was in breach of standard C4 and C5 of the Code (2016) which states you must:

C4: develop, apply and document a plan of care in full agreement with the patient. You must check the effectiveness of the care and keep the plan of care under review. A more formal reassessment of the effectiveness of the plan of care must be undertaken at intervals that suit the patient and their needs. All subsequent modifications to the plan of care must be discussed and agreed with the patient and properly documented.

C5: select and apply appropriate evidence-based care which meets the preferences of the patient at that time.

Allegation 2 - making misleading claims.

There were two decisions in relation to the second allegation.

The Committee found that the content of the video regarding Ménière’s disease, though below the standard expected, was not serious enough to be considered unacceptable professional conduct.

However the chiropractor’s inappropriate and misleading claims in relation to subluxation were so serious a departure from the standards expected of a registrant that they were considered unacceptable professional conduct.

This was in breach of standards B3 and B5 of the Code (2016) which states you must:

B3: ensure your advertising is legal, decent, honest and truthful as defined by the Advertising Standards Authority (ASA) and conforms to their current guidance, such as the CAP Code.

B5: ensure your behaviour is professional at all times, ... thus upholding and protecting the reputation of, and confidence in, the profession and justifying patient trust.

His actions were also in breach of the GCC’s February 2017 Guidance on Claims made for the Chiropractic Vertebral Subluxation Complex.

Sanction

The Committee accepted that the chiropractor had apologised to the patient, and recognised he could have done a formal reassessment earlier. He has not used the leaflet for over a year and has expressed a continued commitment to adhering to GCC standards.

However, there was also a risk of harm (though thankfully no actual harm) to the patient, and the statements about subluxation were a serious departure from standards and specific guidance, and risked undermining public confidence in the chiropractic profession.

The Committee concluded that issuing a suspension was the most appropriate and proportionate sanction in this case.

Learning for registrants

While it is important to create an individual care plan at the start of treatment, the plan must be reviewed and reconsidered appropriately, in discussion with the patient, as you get further information. This is covered by standard C4 of the current Code.

From 1 January 2026, Principle D of the Code of Professional Practice expands the description of the steps involved in providing patient-centred care (diagnosis, planning care, evaluating care and providing care). This change was made because our stakeholders, including patients, told us of their concerns about the potential for unnecessarily long care plans to be implemented without justification, and their concerns that reviews of care may not be meaningful.

Standards D9 and D10 of the new Code of Professional Practice focus on:

Evaluating and modifying the plan of care

D9: continuously monitor and record the patient’s progress towards their planned health outcomes, evaluating and adapting the plan of care to meet their needs. You must carry out formal clinical reassessments at regular intervals, using recognised outcome measures to evaluate the effectiveness of care, as previously agreed with the patient and set out in their plan of care.

D10: discuss with the patient their progression towards their planned health outcomes, agree any continuation or modification to their plan of care and record valid consent.

Further reading

GCC Guidance (February 2017) on Claims made for the Chiropractic Vertebral Subluxation Complex.