Timeline of Events, Healthcare Provider Errors, and Patient Decision-Making in the Case of Joanna Kowalczyk
Originally published: 2025-02-01
September 26, 2021 – Initial Injury at the Gym
Joanna Kowalczyk felt a crack in her neck while using gym equipment during a personal training session. She developed a severe headache.
Medical Implication: It is likely she sustained bilateral arterial dissections at this time due to an undiagnosed connective tissue disorder that made her prone to arterial injuries.
Patient Decision: No immediate medical treatment sought.
September 27, 2021 – Visit to Emergency Department
Joanna sought medical attention at the Emergency Department due to persistent pain and concerns over her symptoms.
Medical Evaluation:
A CT scan was performed to check for a subarachnoid hemorrhage (brain bleed).
No hemorrhage was found.
A lumbar puncture was recommended to rule out other serious conditions.
No angiograms, MRI’s, MRA’s or other necessary testing was performed
Patient Decision: Joanna self-discharged from the hospital before undergoing the lumbar puncture.
Error: The hospital failed to diagnose her arterial dissections, and there is no mention of further vascular imaging being performed.
Patient Action: While waiting in the hospital, Joanna researched alternative treatments and chose to see a chiropractor.
September 28, 2021 – First Chiropractic Visit
Joanna visited a chiropractor for the first time, reporting neck pain.
Chiropractor’s Assessment:
Diagnosed with acute severe cervical facet dysfunction and associated muscle dysfunction.
Recommended adjustments and manipulations, which she consented to.
Patient Disclosure: Joanna informed the chiropractor that:
She had attended the hospital and had a CT scan.
Further medical investigations had been recommended, but she self-discharged.
Her doctor was aware she was seeing a chiropractor.
Chiropractor’s Decision: Did not obtain medical records before treatment.
Treatment Outcome: Joanna reported some improvement in her neck pain.
October 2, 2021 – Second Chiropractic Visit
Joanna received her second chiropractic adjustment.
Treatment Outcome: No reported adverse effects.
October 9, 2021 – Third Chiropractic Visit
Joanna underwent a third chiropractic session.
Treatment Outcome: No reported adverse effects.
October 16, 2021 – Fourth Chiropractic Visit and Stroke Symptoms Begin
During her fourth chiropractic session, Joanna received a left neck adjustment and immediately experienced:
Dizziness and room spinning
Double vision
Tingling in her right hand and foot
Speech difficulties
Vomiting
Chiropractor’s Actions:
Conducted a FAST stroke test, which was negative.
Consulted a second chiropractor for an opinion.
Advised Joanna to go to the hospital—she refused.
Allowed her to rest for several hours in the clinic before she left with assistance from her partner.
Gave her a handwritten note advising her to seek emergency medical attention if symptoms worsened.
Patient Decision:
Refused to go to the hospital despite experiencing symptoms suggestive of stroke.
Left the clinic with mobility issues, requiring assistance from her partner.
Chiropractic Clinic Error: Did not call an ambulance despite symptoms, relying on her improvement.
October 16, 2021 (Later That Day) – Paramedic Assessment and Misdiagnosis
Joanna’s speech difficulties worsened, and an ambulance was called.
Paramedic Actions:
Performed a FAST test, which was negative.
Spoke to the chiropractor, who stated symptoms of dizziness and migraine were common after adjustments.
Diagnosed Joanna with a migraine instead of a potential stroke.
Did not observe or record her inability to walk unaided.
Patient Decision:
Accepted the paramedic’s assessment of migraine and did not insist on hospital transport.
Healthcare Provider Error:
The paramedic failed to recognize stroke symptoms, as stroke symptoms can be transient.
No transport to the hospital despite neurological symptoms.
October 17, 2021 – Critical Deterioration and Emergency Hospital Transport
Joanna’s condition worsened significantly.
Symptoms:
Reduced consciousness
Severe neurological impairment
Paramedic Response:
Arrived via blue-light ambulance.
Could not perform a FAST test due to her condition.
Transported her immediately to the Emergency Department.
Healthcare Provider Error: Had the previous paramedics recognized stroke symptoms on October 16, she may have been treated sooner.
October 17-19, 2021 – Hospitalization and Death
October 17:
CT scan identified a large brain infarction (stroke) affecting her posterior brain structures.
CT angiogram confirmed a left vertebral artery dissection.
Neurology specialists determined no treatment was available.
October 19:
Brainstem function tests confirmed death at 13:10 at Queen Elizabeth Hospital in Gateshead.
Key Healthcare Provider Errors Identified in the Coroner’s Report
Hospital Emergency Department (September 27, 2021):
Failed to diagnose arterial dissection.
Did not perform vascular imaging to detect vertebral artery injury.
Did not insist on keeping Joanna for further monitoring.
Chiropractic Clinic (October 16, 2021):
Did not call emergency services immediately despite symptoms of stroke.
Relied on negative FAST test and temporary improvement in symptoms.
First Paramedic Crew (October 16, 2021):
Misdiagnosed stroke symptoms as a migraine.
Did not recognize transient stroke symptoms (which is basic stroke education).
Did not document her inability to mobilize unaided.
Did not transport her to the hospital.
Key Patient Decision-Making That Contributed to the Outcome
September 27, 2021:
Self-discharged from the hospital against medical advice, refusing a lumbar puncture.
Researched alternative treatments and chose chiropractic care.
October 16, 2021:
Refused to go to the hospital despite being advised to by two chiropractors.
Accepted the paramedic’s migraine diagnosis instead of seeking further medical evaluation.
Conclusion
The initial arterial dissection likely occurred at the gym, not due to chiropractic care.
Medical professionals failed to diagnose her vascular injury at the Emergency Department.
The paramedics misdiagnosed stroke symptoms, delaying critical treatment.
Joanna actively made decisions that impacted her care, including refusing hospital treatment multiple times.
Despite these key factors, the media narrative falsely frames chiropractic care as the cause of death, ignoring systemic failures in emergency medicine.
Click Below for the other articles in this series that break down the case:
What the News Reported vs. Reality – Analyzing the logical fallacies and disinformation in media coverage.
What the Coroner’s Report Actually Said – Examining Joanna’s medical timeline and the failures of emergency medicine and paramedics in properly diagnosing and treating her condition.
A Detailed Timeline of Events & critical decision making errors
Risk Management Strategies for Chiropractors – Providing evidence-based recommendations to ensure chiropractors can mitigate risks and protect both their patients and their profession in similar cases.
