First aid training should be mandatory for chiropractors, a coroner said at the end of the case of a man whose neck broke during chiropractic treatment.
John Lawler, 80, died in hospital a day after becoming unresponsive at Chiropractic 1st in York in 2017.
Jonathan Heath, assistant coroner for North Yorkshire, found Mr Lawler suffered a fractured neck and spinal cord injury while undergoing treatment.
He said he would recommend changes to the General Chiropractic Council (GCC).
It emerged during the six-day hearing that Mr Lawler had a condition in his cervical spine meaning it was far more rigid than a healthy spine.
Over time the ligaments along the cervical spine had become bone-like resulting in limited movement in his neck.
Medical experts said the condition was abnormal but not uncommon in older people.
It can be visible on imaging, such as a CT scan, but the inquest heard that imaging is no longer common before chiropractic treatment.
Mr Lawler had sought treatment after complaining of aches in his legs in 2017.
He visited Chiropractic 1st with his wife at the end of July and booked three sessions for the first week of August with Mrs Arleen Scholten.
During treatment on 11 August 2017 Mr Lawler suddenly moaned and said he could not feel his arms and became unresponsive.
The chiropractor manoeuvred him onto a chair and gave mouth-to-mouth until the ambulance service arrived.
The inquest has heard that had Mr Lawler been immobilized immediately after the fracture he would have survived.
Delivering a narrative conclusion, Mr Heath said Mr Lawler had died from the fracture to his neck and resulting spinal cord injury, while undergoing chiropractic treatment, which led to respiratory depression.
He said he would be writing to the GCC with two recommendations.
He would request it carries out a review of the requirements for pre-treatment imaging, and secondly, to consider first aid training being made mandatory for chiropractors.
'Rare and unusual'
Speaking after the hearing, the Lawler family said it hoped the publicity surrounding the case "will highlight the dangers" of chiropractic practice, especially for the elderly and those with "already compromised spines".
"We would again urge the regulator to take immediate measures to ensure the profession is properly controlled," they said.
A representative for Mrs Scholten said she wished to express her "deepest sympathies" to Mr Lawler's family.
"This was an extremely rare and unusual incident, which has been thoroughly investigated by the Coroner during the course of the inquest," he continued.
"She will take on board the Coroner's findings, and has already made changes to her practice since the incident."