Coroner's Finding: COOKE Rowan Douglas

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 5th, 6th and 8th days of June 2007, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Rowan Douglas Cooke.

The said Court finds that Rowan Douglas Cooke aged 37 years, late of 21 Langton Street, Glenroy, Victoria died at Yankanina Station, Flinders Ranges via Leigh Creek, South Australia on the 3rd day of November 2004 as a result of dehydration/heat related death. The said Court finds that the circumstances of his death were as follows:

1. Background 1.1. On Wednesday, 27 October 2004 a group of eleven adults comprising seven men and four women, whom I will refer to as the group of eleven, travelled to the Gammon Ranges in the far north of South Australia to participate in a ‘vision quest’, a ritualistic practice that often involves the use of a ‘sweat lodge’. A vision quest is an exercise in which the individual participants seek a vision, an obscure experience that for different persons can mean different things. A sweat lodge more or less performs the same function as a sauna, but unlike a sauna it is not necessarily a permanent structure, being fashioned out of sticks, cloth and other material and the temperatures within it may be less controlled than those in a sauna. It is usually erected in association with some form of spiritual endeavour and, as was the case here, can be erected on the spot. Whether by design or otherwise a sweat lodge often resembles a Native American tepee. Heated rocks are placed in the sweat lodge and water is poured over them creating steam and, at times, intolerable temperatures within.

People remain inside the lodge in these conditions for whatever physical, spiritual or

emotional advantage they think they might gain. The belief systems underlying the use of sweat lodges range across a broad spectrum, from the mundane and harmless to the plain silly yet dangerous. The evidence would suggest that at either end of the spectrum, suspension of one’s grasp of reality for the duration of a sweat lodge is de rigueur.

1.2. The group of eleven were all mature adults. One of them, Rowan Douglas Cooke, 37, was in good health but he met his death when, in the course of the expedition, he collapsed in a sweat lodge through dehydration and exposure to the heat. He died as a result.

1.3. This incident occurred on private property known as the Yankaninna Station. The site chosen for the rituals was a creek bed about 10 kilometres from the Owiendana homestead. The station was managed by Mr Paul Doran who resided at the homestead. Permission for the group of eleven to enter and remain on the station property was neither sought from nor given by Mr Doran. Mr Doran had no knowledge of the presence of this group of people on the property, even though they had been there from Thursday evening, 28 October 2004 until the morning of Wednesday, 3 November 2004, the day of the fatal incident. The location at which the group of eleven made their camp and conducted their rituals was remote. The site was approximately 75 kilometres from Leigh Creek by way of dirt roads. The nearest hospital and ambulance depot were situated at that town. Volunteer crews staffed the ambulance depot at Leigh Creek. The nearest professional paramedics were stationed at Port Augusta about 250 kilometres by road from Leigh Creek. One of the Port Augusta paramedics happened to be in the Leigh Creek area on that Wednesday. He and a number of volunteer South Australian Ambulance Service (SAAS) officers were to attempt unsuccessfully to save the deceased’s life. I return to the involvement of the SAAS in due course.

1.4. Mr David Jarvis, 46, was one of the group of eleven. He had been to the location of the campsite on a prior occasion and its remoteness was a matter that was, on his own admission, well known to him.

1.5. A number of statements have been tendered to the Inquest by Ms Amy Davis, counsel assisting the Court. I thank Ms Davis for her considerable efforts in this Inquest. In addition, Ms Davis adduced oral evidence from the police officer who investigated

this death on behalf of the State Coroner, Senior Constable Peter Stirling of the Port Augusta Criminal Investigation Branch. I accept his evidence in its entirety. I thank Mr Stirling for the thoroughness of his investigation. I also heard oral evidence from Professor Roger Byard who, together with Dr Karen Heath, performed the post-mortem examination in respect of the deceased’s remains. I accept Professor Byard’s evidence in its entirety. Each of the group of eleven persons involved in this matter gave witness declarations to the police shortly after the incident in question.

The contents of those statements speak for themselves. There are no suspicious circumstances surrounding this death. I did not feel it necessary for any of those persons to be called to give oral evidence apart from Mr Jarvis who did give evidence before me. Ms Prudence Blackmore, who is a ceremonial leader in an organisation that conducts sweat lodges known as SOTEMS, the Spirit of the Earth Medicine Society, and who was not involved in the incident in question, also gave general evidence about these practices.

2. Reasons for Inquest and conclusions 2.1. In this Inquest I examined a number of matters that required investigation. The broad conclusions are as follows. Firstly, the foolhardiness of conducting a ritual of this nature in the manner and circumstances revealed by the evidence is plain for all to see. Mr Cooke died because of the intolerable conditions to which his body was subjected during the ritual. Secondly, there was an inordinate length of time before any meaningful help was sought for the deceased when it should have been obvious that he was in a terrible state following his collapse and that he required urgent medical intervention. Thirdly, it does not seem to have occurred to anybody involved in this expedition that the remoteness of the location was going to inhibit timely and appropriate medical attention for anyone who might be injured or who might become acutely ill. Fourthly, notwithstanding the obvious intrinsic dangers of a sweat lodge, there was no preparation or thought given to what action might be required in such an emergency. Fifthly, while it was not intended during the course of the Inquest nor in these findings to denigrate anyone’s spiritual beliefs, it has to be placed on public record that the extreme nature of some of those beliefs, as revealed by the evidence that I heard, played a significant role in the failure to secure timely and appropriate medical attention for the deceased.

2.2. The undesirability of imposing unnecessary strictures on the rights of citizens in our nation to conduct their spiritual and recreational pursuits of choice hardly requires stating. However, this Inquest was conducted in the hope that the public exposure of the folly that surrounded this sorry affair might mean that a death such as this will not be repeated.

3. A sweat lodge 3.1. The use of a sweat lodge is generally based on Native American and other indigenous beliefs and traditions. In this particular case its use was said to have been based upon Native American belief systems. There were items located at this scene that one normally associates with Native American culture such as peace pipes and feathers.

3.2. A sweat lodge is used for different kinds of ritualistic behaviour, but the common theme for its use involves cleansing, purification and the attainment of peace. Its significance to the group of eleven is encapsulated in the following statement made by one of its members, Mr Jarvis, when explaining its use to the investigating police: 'It’s a structure used for purification, cleansing, prayer, honouring and it’s also used for particular ceremonies or rights of passage for people who choose to walk into different types of powers that they might to, whether it be a drum, a pipe, or even just a particular feather can be activated by doing a ritual of cleansing and giving back our sweat and tears to the earth, to heal the whole planet.' 1

3.3. The sweat lodge’s framework consisted of 16 tree branches bound together in the shape of a tepee together with horizontal rows of poles that added structural support.

Covering material was thrown over the structure; the first layer appeared to be reflective building insulation and over that were several layers of blankets, quilts and tarpaulins. The insulation was designed to keep the heat within the structure. The lodge was about 1.2 metres in height and was roughly circular in shape at its base with a diameter of about 3 metres. Entry to the structure was gained by a rectangular door that was about 70cm high and about 50cm wide. The floor of the lodge was the bare earth on which it had been erected, in this case the coarse gravel of a creek bed.

A pit of about 30cm in depth had been dug in the middle of the bare earth floor and a number of rocks had been placed in it. There were 39 rocks in place when it was examined by the police. They were estimated to weigh about two kilograms each.

Exhibit C22c, page 1

The rocks had been heated and had been brought into the structure during different phases of the ritual. The rocks are traditionally known as Grandfathers. There was some decoration hanging from the roof of the structure.

3.4. Around the structure and campsite generally were other ritualistic items including feathered staffs, drums, the remnants of stone ceremonial pipes, didgeridoos and a formation of rocks that had been placed in a circle resembling a miniature Stonehenge. There was also an altar / fireplace which had been utilised to heat the rocks that had been placed into the sweat lodge during the ritual.

3.5. I add here that there is no suggestion that illicit substances or alcohol formed any part of what had taken place.

3.6. The sweat lodge was capable of accommodating a number of people at a time. The ritual that had culminated in the deceased’s collapse had involved the presence of three people within the structure.

3.7. It was evident from the way the sweat lodge had been constructed that it was capable of containing a great deal of heat. It is said that temperatures of up to 60 degrees centigrade can be generated in makeshift sweat lodges. The amount of heat generated depends on the heat of the rocks and the amount of water poured onto them. Control of the temperature within the structure would therefore involve an element of uncertainty. Prolonged exposure to such temperatures can be dangerous. It can lead to dehydration, tissue degeneration, collapse, unconsciousness, lack of control of one’s bodily functions and death.

4. The circumstances leading up to the deceased’s participation in the sweat lodge ritual

4.1. Evidently this was not the first time that the deceased had been involved in this kind of ritualistic behaviour. He was no novice in respect of what was to take place. Some might therefore say that he was in some measure the author of his own misfortune. In my opinion the matter cannot be viewed so simplistically. As will be seen, whether he appreciated the risks or not, his death should have been avoided. Others in this party, by comparison to Mr Jarvis and the deceased, seem to have been relatively naïve. For example, in describing the indecision about what should be done to assist

the deceased following his collapse, one participant states with breathtaking naivety, ‘at this time I did not know whether this situation was a normal part of the process or not’2. The crisis elicited other unusual responses that appear to have been underpinned by the unshakeable conviction that, rather than the deceased being profoundly unwell, he was experiencing some kind of supernatural phenomenon. I return to this later.

4.2. As earlier recorded, the party had left Victoria on Wednesday, 28 October 2004.

They had travelled in a number of vehicles, at least one of which was a 4WD. The expedition was well equipped with food, water and shelter. The party spent the Wednesday night at the Adelaide Hills premises of a friend of Mr Jarvis. That evening a sweat lodge was conducted without incident. The following day the party travelled up to the Flinders Ranges arriving some time in the late afternoon. They set up camp on the property that I have described.

4.3. In the ensuing days a number of rituals were conducted including the vision quest which involved the individuals isolating themselves from each other and striving for a vision that may or may not materialise. A number of sweat lodges were also conducted without incident. It is believed that the deceased himself was involved in two sweat lodges prior to the one that eventually claimed his life.

4.4. The exercise also involved the members of the group fasting for several days, although people were encouraged to take as much fluid as possible and that included water, fruit juice, Gatorade and the like. Some witness statements suggest that although the deceased was initiated in these matters, he may not have been as careful as others in relation to the taking of liquid prior to his participation in the fatal sweat lodge. It is possible that by the time he came to participate in this sweat lodge, having been in two already, he was not ideally prepared in terms of hydration. Mr Jarvis said that he did not observe whether the participants in the fatal sweat lodge had been taking fluids during the day. He told me that he did not consider it necessary for him to do so in the light of their previous experience in sweat lodges.

Exhibit C11, page 7

5. The fatal sweat lodge ritual 5.1. This particular ceremony had three participants. Apart from the deceased, a woman by the name of Maureen Collier aged 48 years and another male by the name of Adrian Asfar aged 30 years also participated. The preparation for the ceremony is described in the witness statement of Ms Collier dated 4 November 20043.

Preparation commenced on the Tuesday and according to Ms Collier they consumed food and drink - a great deal of fluid. I think she was there speaking for herself because as seen earlier other evidence would suggest that the deceased had not consumed as much fluid as he might have given the nature of the exercise in which he was to participate. The underlying spiritual purpose of a sweat lodge can vary and the evidence is less than crystal clear as to what the purpose of this particular sweat lodge was except that it involved the initiation of the three participants to become pipe bearers. This ceremony involved the use, or at least the presence of, stone pipes called peace pipes and the ceremony was apparently designed to reveal whether or not the participants were worthy of the status. The initiated may conduct certain ceremonies in Native American tradition. The pipes are placed on an altar and are packed with tobacco. Once activated by the ceremony, the pipes are taken up and the bearers then walk into their new role in life. Each of the three participants was expected to perform his or her chosen ritual during the ceremony, such as the singing of a song, the telling of a story or chanting; so the ceremony was therefore of some duration.

5.2. The three participants spent some hours in the sweat lodge before the hot stones were introduced. David Jarvis in his statement dated 4 November 20044 claims to have been in the business of running sweat lodge purification ceremonies and had been doing so for about four years prior to November 2004. He described himself to the police as a new age healer. He claims to have had some insight into what was taking place and he describes his own role as one in which he, because of his greater knowledge of the subject, was ‘sitting on the bank and at times I smoked my sacred pipe, sending prayers out and welcoming them in, ah in spirits’5. Others were involved in the preparation and heating of the stones and in the delivery of the stones Exhibit C8 Exhibit C12 Exhibit C22c, page 5

to the sweat lodge. One of those persons is called the fire keeper and the role of the fire keeper is described as follows: 'The fire keeper will then approach the lodge and flick the door open and steam that has been created in the lodge flows out releasing spirit, the prayers to spirit so it’s going up, so the steam has a particular role of sending the prayers out into the cosmos.' 6 Mr Jarvis said that no one individual was in charge of the ceremony, and resisted the suggestion that he was in charge, saying that he did not think he was present at the beginning of the ceremony in any event. However, it is clear in my view that he was certainly one person who was vested of an intimate knowledge of the nature of this exercise.

5.3. In her statement Ms Collier describes events within the lodge after the heated stones were introduced7. It is unclear what time it was when that occurred, but it was some time in the early hours of the Wednesday morning. Ms Collier’s statement does not describe times over which various features of the ceremony occurred. However, there are estimates by others as to time. The 39 stones had been placed in the lodge one at a time. They were carried from the fireplace to the lodge by the fire keeper with the use of a garden fork and then handed to an occupant who accepted them with some other implement. They were then individually blessed and placed one by one into the centre pit. This must have taken some little time. Ms Collier states that to begin with, 18 stones (Grandfathers) were placed into the centre pit and each one of them was duly blessed by the deceased as they were introduced8. The door to the sweat lodge was then closed and the first ‘round’ of the ceremony, which involved praying for the earth and the injustice in the world, then occurred. During the course of this round, water from a bucket was poured on the rocks thereby creating heat and steam. Ms Collier states that she was aware that if too much water were to be poured onto the heated rocks excessive heat would be created. In due course another lot of stones were brought into the sweat lodge. Ms Collier maintains that Mr Jarvis told the deceased not to use too much water early in a round. The next round involved the deceased praying audibly and telling a story. Ms Collier describes the interior of the sweat lodge as becoming very hot. Ms Collier states that she does not normally notice Exhibit C22c, page 4 Exhibit C8 Exhibit C8, page 2

the heat in a sweat lodge ‘as I am in a different place’9, but on this occasion she was very conscious of the heat to the point where she urged the deceased to quicken the pace of his part of the ceremony. The deceased poured more water on the rocks and then appeared to go quiet, although Ms Collier states that in her experience this is quite normal. She states that the other participant, Mr Asfar, was still responsive at that stage. According to Ms Collier she again urged the deceased to hurry up because of the heat. At this time, however, he did not respond. She attributed this to his preoccupation with his role in the ceremony. Some chanting by Mr Asfar took place at the conclusion of which he was also unresponsive. From the tone of Ms Collier’s statement it is at about that point she quite clearly started to experience a measure of discomfort and anxiety about the environment within the sweat lodge and so decided to leave the ceremony prematurely. Ms Collier says that both of the men were unresponsive at that stage. She called out for help and someone opened the door to the sweat lodge. She emerged. By then, Ms Collier was physically compromised herself.

5.4. The two men were dragged out of the sweat lodge. They were manifestly unconscious and unresponsive. Paradoxically, they were both wrapped in blankets when what they required was cooling.

5.5. In his statement10 Mr Asfar describes his own ordeal. He also was not new to the ritual, having participated on three or four previous occasions. He participated in a sweat lodge on the Wednesday night in the Adelaide Hills and in two others at the Flinders site. The first of these lasted about 40 minutes and the second about 20 minutes. He also participated in the vision quest which took place in the 24 hour period between Saturday morning and the Sunday morning.

5.6. Mr Asfar expected the pipe ceremony in the sweat lodge to take only about 30 minutes, but like many of the others does not seem to have much conception of time as far as the duration of the fatal sweat lodge is concerned. In the 6 hours or so before entering the lodge, he had consumed about a litre of water and about 600ml of Gatorade. He did not know how much liquid the deceased had consumed.

Exhibit C8, page 3 Exhibit C21

5.7. In his statement to the police Mr Asfar provides a description of what happened in the lodge. He describes nothing out of the ordinary at first, except the presence of an unusual odour that he attributes to the water that was being used which he thinks may have been bore water. He recalls feeling very hot and that he was lying on the ground to seek relief from the heat. The deceased and Ms Collier were also lying down, but the deceased seemed to be fine. However, it is plain that the heat overwhelmed them all. Mr Asfar himself said that he felt so weak that he was unable to speak. His next memory is being in the ambulance on the way to the Leigh Creek Hospital.

5.8. Mr Asfar postulates that the quality of the water may have had something to do with their collapse. This can be discounted. Heavy metal analysis of the bore water taken from the scene by the police did not show elevated levels of any toxic metals such as arsenic, lead or mercury11. In addition, the finding of significant dehydration in two of the participants, with rapid recovery of Ms Collier upon her removal from the heated environment, would not be supportive of this possibility. Mr Asfar’s recovery upon rehydration is also not a feature of heavy metal poisoning.

5.9. When Mr Jarvis spoke to the police at the scene he said that he had interpreted the events in these terms: that he had noticed a particular energy coming out of the sweat lodge that he had not seen before. It was an energy source quite strong in nature and for him the two people in the lodge were having an out of body experience. He had noticed a change in the tone of voice of those in the sweat lodge and had believed that it had been part of their prayer process. When Ms Collier had started yelling to be let out of the sweat lodge, Mr Jarvis’ initial reaction was to pick up a ceremonial staff with a feather attached to it and to cut the energy that was in play with the feather12.

He then opened the door and states that he noticed that the deceased ‘appeared to be unconscious’13. The deceased was then removed from the sweat lodge along with Mr Asfar. In Mr Jarvis’ formal witness statement he reiterates what he had told the police earlier and says that although at that point in time there was some panic on the part of those present, he thought that the two men were still travelling and having an out of body experience. Mr Jarvis’ evidence before me about the way he saw these events was consistent with what he had told the police in November 2004. He added that at one point in time he had noticed that the lodge did not seem to have its usual energy, Exhibits C17 and C17a Exhibit C22c, page 8 Exhibit C12, page 4

it was not in its ‘hum’ – it was out of alignment and it was not complete. Mr Jarvis walked around the lodge and at that stage Ms Collier said that there was something wrong. She started yelling ‘Get me out of here’14. They threw open the lodge and Ms Collier emerged. Jarvis says that she was not well. While acknowledging that the deceased was removed from the lodge in an unconscious state, Jarvis said it was like he was in a ‘deep sleep’. He said that he had seen this happen before to people and that it was not uncommon for them to go into this deep sleep. He had seen a particular energy force outside their bodies, but it was one that was still connected to their bodies. In his experience, drumming brings them back into consciousness - ‘You call them back, you drum them in’. He himself had experienced this out of body phenomenon - a deep shut down state that had culminated, on his own admission, in him being ill and vomiting after regaining consciousness, as if the same were to be viewed as nothing out of the ordinary. Mr Jarvis admitted that he really had no idea how one would distinguish a clinically unconscious person from one who was in a deep trance. The respective conditions of Mr Asfar and the deceased when removed from the lodge were therefore to be viewed against that sort of belief system, a belief system that did not augur well for their survival.

5.10. The length of time in which the deceased and the other participants had been in the sweat lodge prior to their removal can only be gleaned from estimates provided by some of the participants. Mr Jarvis was unhelpful in this regard. In his evidence before me he appeared to regard time as an irrelevant consideration when in reality time spent in the lodge must have impacted significantly on the wellbeing of its occupants. Mr Heath Myers, who provided a statement dated 4 November 200415, was one of the fire keepers for this ceremony. Ultimately, Mr Myers was to be the initiator of attempts to obtain medical help after the deceased’s collapse. Mr Myers suggests that the ceremony, and I take it he means from the time of the introduction of the heat into the sweat lodge until the removal of the participants, was about half an hour to 45 minutes, but emphasised that he was not sure about that time16. Mr Kenneth Gifford who provided a statement dated 4 November 200417 was the other fire keeper. His estimates are more considered than those of Mr Myers. Mr Gifford states that the first round involving the placement of the first lot of stones lasted Exhibit C12, page 4 Exhibit C14 Exhibit C14, page 6 Exhibit C15

between 15 and 25 minutes. He states that the first round was not completed satisfactorily and that the participants took approximately an extra 10 minutes.

Another 10 minutes was taken in placing the rest of the stones into the sweat lodge although at that point the doors of the lodge were open. Mr Gifford estimates that they would have been in the sweat lodge for approximately 20 to 25 minutes. After he heard the deceased finish his story-telling he says that things went quiet for about 5 minutes. There was then some chanting by Mr Asfar for about 3 minutes and then there was quiet for about another 5 minutes. He then states that the next thing that took place was Ms Collier asking for the sweat lodge to be opened because of the heat. Mr Gifford describes Mr Jarvis urging Ms Collier to ‘rouse up your brothers’18, upon which Mr Gifford states that he heard Ms Collier trying to attract Mr Asfar and the deceased’s attention. At that point the sweat lodge was opened and the three participants were removed.

5.11. Mr Gifford describes the deceased as appearing ‘in a dream state’19 following his removal. He also makes a point of saying that no-one appeared to be too concerned for the welfare of the two men, but does not provide any basis for saying that.

However, other descriptions suggest that although there was some concern expressed for the condition of the two men, for the most part it manifested itself in bizarre ritualistic behaviour and it was not until Mr Myers adopted a more prosaic approach that medical assistance was sought. Mr Myers and Mr Gifford were to go to the homestead to seek help. I return later to the efforts to revive the deceased and to seek medical assistance for him.

5.12. The above description of events, particularly that provided by Ms Collier, establishes that conditions inside the sweat lodge, regardless of the length of time the three of them had been in there, had become incompatible with the wellbeing of its occupants.

Ms Collier was the only one of the three to have the presence of mind to realise this as a fact. Why the other two participants did not think so is far from clear. However, it may well be from Ms Collier’s description of these events that the two men had become so fixated with the ceremony and with their roles in it that they had become oblivious to the dangers that their environment presented. Indeed, according to Mr Jarvis, Mr Asfar has since confided that he attributed his personal ordeal to an out of Exhibit C15, page 3 Exhibit C15, page 3

body experience. The evidence suggests that this experience is a goal of some devotees of the practice.

5.13. We do not know with certainty what time of the morning it was when the deceased and Mr Asfar were removed from the sweat lodge. However, it was still dark at that time because many of the group describe daybreak as occurring some time after their removal. In the witness box, Mr Jarvis said it was still dark when they were removed but thought that this had occurred not long before sunrise. However, when pressed he thought it could have been as much as an hour before it became light. One point in time that appears to be reasonably ascertainable within limits is the time when Messrs Myers and Gifford arrived at the station homestead and sought help. Mr Doran gives a time of about 8am as the time they came to his door. SAAS were contacted some time prior to 8:32am at which time two SAAS volunteers at Leigh Creek were notified by ambulance communications of the incident on their pagers20. Mr Doran’s wife had contacted the SAAS. Accordingly, it appears that Messrs Myers and Gifford probably arrived at the station homestead sometime between 8am and 8:30am. They had undertaken the 10 kilometre journey from the campsite to the homestead in a 4WD vehicle. We do not know with precision how long that journey took. However, Senior Constable Stirling told me that the road was good enough for a 4WD vehicle to maintain a speed of 80 kilometres per hour. If one assumes that Messrs Myers and Gifford did not dawdle, the trip would only have taken a few minutes. If so, they left the sweat lodge area some time between 7:30am and 8am. These times are relevant in determining the length of time that had transpired between the deceased’s removal from the sweat lodge and Messrs Myers and Gifford going for help.

6. Events following the removal of Mr Asfar and the deceased from the sweat lodge 6.1. According to the Australian Government Geoscience Australia website, sunrise on 3 November 2004 at the location of the campsite, the co-ordinates of which were recorded by the police as 30 degrees 23.066 minutes south and 138 degrees 58.617 minutes east, occurred at 6:17am. In my opinion it can therefore be deduced that the time between the deceased’s removal from the sweat lodge and Messrs Myers and Gifford leaving to get help was considerable. Even if the journey to seek help took as long as half an hour, commencing say at 7:30am, it would mean that the deceased had been lying there unconscious from some time before sunrise at 6:17am until 7:30am Exhibit C4, page 2

before help was sought. In addition, from a description of the activities that took place between those two events, as gleaned from the statements of those who had been present, it can be inferred that the period of time was considerable. Whatever that period of time was, the deceased never regained consciousness. The other male participant, Mr Asfar, was not as adversely affected by his experience in the sweat lodge as the deceased. He regained some level of consciousness, although from any standpoint he was also dangerously ill. The deceased, being unconscious and unrousable for the whole of that period, was quite clearly dangerously ill. Even though he was seen to be breathing, one would have thought that to any sensible and rational person the deceased’s lack of consciousness could only be attributed to one thing, namely that the heat within the sweat lodge had so adversely affected him that his health and wellbeing had become severely compromised. One only needed to have witnessed the state of anxiety in which Ms Collier exited the sweat lodge to realise that conditions within it had become intolerable. The only sensible reaction to all of this would have been for those present to seek, as best they could in the circumstances that they had put themselves in, immediate medical assistance.

6.2. Instead, the condition of the deceased was rationalised by reference to bizarre thought processes. For instance, when Mr Jarvis described these events to the police he stated that when people go on a ‘shamanic’ journey they often do not immediately come back into their bodies. So that when Mr Asfar and the deceased failed to ‘ground in’ after they had been extracted from the sweat lodge, this was seen as the two men still having their shamanic journey or out of body experience21. He does say that the two men were placed into the coma position and an endeavour was made to ensure that their airways were clear. He told me that he thought the deceased’s vital signs were satisfactory. He also says that an attempt was made to give the two men water but they did not drink; and quite clearly this must have been reflective of the fact that they were simply unconscious. What the deceased needed at that point was rehydration by way of an IV saline drip that could only have been provided by professional help. Mr Jarvis’ preferred method of treatment was to obtain his medicine drum, start banging it and to call the two men ‘back to earth’. Mr Jarvis describes Mr Asfar as indeed ‘coming back’ because he started moving22. He seems to attribute this partial revival to his drum banging. Mr Asfar’s lack of recall of the events after his collapse means Exhibit C22c, page 5 Exhibit C12, pages 4-5

that he is unable to shed any light on whether the drum banging played any role in his survival.

6.3. Mr Jarvis says that the deceased, on the other hand, failed to come back and told me that he ultimately concluded that he could be of no further help. Mr Jarvis stated that once it became obvious that the deceased was in a bad way, one of the other persons present, Daniel, suggested that the pipes that had been part of the initiation ceremony be offered as some kind of sacrifice, and that this could be effected by smashing the bowls of the pipes and throwing the stems into the fire. Ms Collier agreed to this.

The other participants, Mr Asfar and the deceased, were in no state to express an attitude. Nevertheless, the strategy suggested by Daniel was embraced with enthusiasm and so all the pipes were broken. Other measures adopted in an endeavour to revive the deceased included the playing of the didgeridoo, further drum banging, chanting and burying the deceased’s feet in the soil, practices that failed to deliver a resuscitative benefit.

6.4. Mr Myers, who states that Mr Jarvis’ contribution to the crisis had consisted of making the observation that all of this was normal and that Mr Asfar and the deceased were astrally travelling, describes the events as follows: 'Everyone was tired, I went back to camp to get some juice, chocolate and muesli bars and brought them back. We all took turns resting and looking after both of them. I then fell asleep for a period of time, to be woken up by Margaret, I checked with her to see that the boys were alright and being looked after, I then fell back to sleep again and when I awoke it was daylight. Adrian was looking a bit better, breathing more steady and Daniel and Karen were looking after him. Adrian was vomiting occasionally.

Rowan’s breathing was heavy but steady, he had bitten his tongue but wasn’t looking good. He didn’t smell good either, he was still, he looked very tired and weak and was breathing steadily and heavily. The group were all applying their various modalities of healing to them including drumming, pressure points, hands-on healing, etc but I noticed that most of the group appeared to be panicking and fear was setting in. I said to David I think it is time to consider a plan B and he agreed. I then urgently clapped my hands and called to everyone drawing everyone together and said that we have to get these boys to medical attention. I said that there was a house about ten minutes away and we could either get them airlifted or driven out.' 23 Messrs Myers and Gifford then drove to the homestead and returned with Mr Doran.

Exhibit C14, page 7

6.5. The journey to the homestead to seek help was long overdue. I do not mean to be critical of Messrs Myers and Gifford about that. They took the initiative, and it meant that Mr Asfar was provided with assistance at a time earlier than if his welfare had been left to others. Mr Jarvis admitted to me that there would have been nothing standing in the way of the group seeking help immediately after the removal of the two men from the sweat lodge. That is plainly right on any view. Mr Jarvis said that he knew that they had passed a homestead on the way in to the camping site and he considered it to be only a relatively short distance away. Senior Constable Stirling told me that the campsite was only a matter of a hundred or so metres away from the road that led to the homestead and that the road was in a satisfactory state of repair.

The journey to the homestead could therefore easily have been undertaken in the dark.

If help had been sought as soon as it was realised that the deceased had lost consciousness, there does not appear to have been any reason why they could not have conveyed the two men to the homestead by sunrise. Much time was needlessly wasted. There was nothing pragmatic about the reason why help was not sought at the earliest available opportunity. Mr Jarvis told me that as far as he was concerned the reason help was not sought was because he had believed both men would come in from their out of body experiences. Once Mr Asfar had come in, he thought the deceased would follow. It was only when he did not come in that he thought he needed help.

7. Medical assistance for Mr Cooke is sought 7.1. When Messrs Myers and Gifford attended at the homestead, the SAAS were called and, as seen earlier, two volunteer officers were alerted at 8:32am. Messrs Myers and Gifford returned to the location of the deceased in company with Mr Doran. Mr Doran describes the situation in these terms: 'I was then shown to where the patients were. The other people present at the camp (about 6 or 7) were standing about 4 feet away and were either banging drums or hugging each other. No one was attending to them. Both were lying down on blankets and were also covered with blankets. One was under about four blankets, two of those were double folded and this would have been equivalent to being under about 6 blankets.

He was extremely hot and I removed the blankets to help cool him down. He (sic) face was also flushed and the rest of his body was sickly white and he appeared to be in shock. He had short rapid breaths and every so often seemed to get a deep breath in.

He appeared to be unconscious the whole time I was there. I checked his pupils and they

were pin prick in size. I also saw that he had defecated and it was all over his back.

Some was dry on the blanket and his skin and he appeared to have been in it for a while, so it appeared he hadn’t been checked and under the blankets for a while. I asked someone to quickly clean him up as I was concerned about my own health if I was going to help him. He was then wrapped in a sheet and placed in the back of my car. I told the others to put the other guy in their car and follow me and to stop off at my house and see her if they needed any help. I would have only been at the camp site for about 3 to 5 minutes in total.' 24

7.2. Senior Constable Stirling told me that Mr Doran’s homestead was about 10 kilometres towards Leigh Creek and just off the road. By not taking the deceased with them when Messrs Myers and Gifford went for help, it meant that an additional 20 kilometres was added to any journey that was going to be undertaken to Leigh Creek.

There was also a corresponding waste of time. Mr Jarvis accepted this, but could not explain why the deceased was not taken with Messrs Myers and Gifford when they went for help. After Mr Doran dealt with the situation at the campsite as best he could, he drove his vehicle towards Leigh Creek. A number of the group of eleven travelled as well. Mr Asfar was taken in one of the group’s 4WD vehicles. At a point about 20 kilometres out of Leigh Creek they met the crew of volunteer SAAS officers that had been despatched from Leigh Creek.

7.3. The SAAS crew consisted of Sandra Evans and Christine Harris whose statements I received in evidence25. Ms Evans and Ms Harris had 2½ and 3 years SAAS experience respectively. They met the party conveying the deceased at about 9:08am.

The vehicle containing Mr Asfar was at that stage some distance behind. Ms Evans’ and Ms Harris’ statements describe in some detail the measures implemented to resuscitate the deceased. He was removed from the vehicle onto a stretcher. The deceased was in a very bad way. Lividity, or the gravitational pooling of blood in the tissues, was already present. As well, his eyes were glazed and his pupils fixed.

What carotid pulse there was was very weak and only occasionally present if at all.

Breathing was said to be negligible if non-existent. Professor Byard told me in evidence that these were signs, especially the lividity, that were very much indicative of death already having taken place.

Exhibit C17, page 2 Exhibits C4 and C5

7.4. Notwithstanding the hopelessness of the situation, Ms Evans and Ms Harris commenced CPR and the deceased was given oxygen. Authorisation to administer adrenaline was sought from, and given by, Dr Hugh Grantham, Medical Director of the South Australia Ambulance Service.

7.5. Mr Shaun Rieck was a full-time SAAS paramedic stationed at Port Augusta. He was present at the Leigh Creek mine conducting a training exercise. At 9:10am he was notified of the fact that the Leigh Creek SAAS crew were attending an incident on the Arkaroola Road and was advised that the patient in question was very unwell. He and two mine rescue crew members, Messrs Smith and Place, who as it happened were also volunteer SAAS officers, left the mine and travelled to the scene in the mine’s troop carrier ambulance. They arrived at 9:44am. By then the vehicle carrying Mr Asfar had also arrived at the scene.

7.6. Mr Rieck attended to the deceased who was clearly the worse of the two men. Mr Rieck observed that his pupils were fixed and dilated with no respirations or pulse with cyanosis and lividity. Notwithstanding these observations, he cannulated the deceased and administered a drip and more adrenaline but with nil response. CPR was continued with further adrenaline being administered. A carotid pulse was achieved at one point. The deceased was loaded into the ambulance at 10:13am and they set off for Leigh Creek. CPR and adrenaline administration continued. They arrived at the Leigh Creek Hospital at 10:38am. At one point en-route the deceased’s cardiac output was such as to enable defibrillation, but any benefit was short lived. At the hospital Mr Cooke was observed to be cyanotic, with fixed and dilated pupils and had no vascular output26.

7.7. Resuscitation efforts continued at the hospital but they were unsuccessful and Mr Cooke was pronounced dead at 11:32am.

8. The post-mortem examination of Mr Cooke and the cause of death 8.1. Professor Byard’s post-mortem report, together with an article about this incident cowritten by Professor Byard and Dr Heath that was published in the American Journal of Forensic Medicine and Pathology, were tendered at the Inquest and became Exhibit C23a. Professor Byard gave evidence before me that augmented his written material.

Exhibit C1

8.2. Professor Byard expressed the cause of death in his post-mortem report as dehydration/heat related death. I find this to be the cause of the deceased’s death.

The basis of Professor Byard’s conclusion is expressed as follows: 'Death was attributed to dehydration given the circumstances of the fatal episode and the finding of a vitreous humor sodium of 156 mmol/L. Levels above 155 mmol/L are considered to represent dehydration. In addition, it is possible that this was higher given that intravenous fluids were administered during attempted resuscitation. It is also likely that high environmental temperature contributed to death, although the diagnosis of hyperthermia is difficult to make at autopsy as there are no pathognomonic features and the body had obviously cooled considerably since the time of exposure to the reported elevated temperatures. Although it has been proposed that a diagnosis of death due to hyperthermia should include a body temperature of 40.6 Celsius or higher, with a high environmental temperature at the death scene (greater than 37.8 Celsius), body decomposition and a history of a person being alive with the high environmental temperature, it is not always possible to fulfil all of these criteria. The term “heat related death” is the terminology recommended by the National Association of Medical Examiners when exposure to high ambient temperatures has either caused death or significantly contributed to it, but the body temperature at the time of the collapse/death cannot be determined.

The areas of parchmenting and abrasion may well have occurred during removal of the body from the hot environment with superficial burns being sustained from heated rocks.

There were no medically significant injuries present. The minor injuries that were present corresponded to the description of the incident.

There were no underlying organic diseases present which could have caused or contributed to death. Blood carbon monoxide level was 1% and alcohol and common drugs were not detected on toxicological screening.' 27

8.3. Professor Byard told me in evidence that prolonged exposure to heat can also cause hyperthermia which in turn can result in the degeneration of bodily tissues, a condition commonly known as organ or muscle meltdown. There were no tissue markers for hyperthermia in the deceased. Professor Byard attributed this to a relatively short time frame from overheating to death and to the fact that dehydration was an important component to terminal metabolic compromise. While the possibility of tissue degeneration from over-heating should be a matter of concern to those minded to participate in sweat lodges, just as it is to endurance athletes, it must Exhibit 23a, pages 1-2

be borne in mind that dehydration is the one factor that can compromise one’s bodily functions and consciousness quickly in a heated environment. Professor Byard writes in his article: 'Individuals who engage in such practices need to be made aware of the potential dangers of overheating and the importance of maintaining good hydration. People with underlying significant cardiovascular disease, certain medications, and recent heavy alcohol consumption should be discouraged from participating in such activities.' 28

8.4. In Professor Byard’s opinion the deceased’s wellbeing would not have been helped by having been wrapped in blankets. Careful cooling is the obvious and preferred approach. Professor Byard made the observation that his being wrapped in blankets probably accounted for the unusually high level of bodily warmth that was still apparent at the Leigh Creek Hospital notwithstanding that he had probably been deceased for some time prior to his arrival.

8.5. Professor Byard has also recorded in the above passage the existence of a number of injuries to the deceased’s person including burns that had also been noticed by ambulance personnel. It has been suggested that these burns were possibly sustained when he was dragged out of the sweat lodge. However, according to Mr Jarvis the deceased was not dragged over the hot stones, but was removed from one side of the lodge after the fabric had been lifted. In addition, Senior Constable Stirling told me that the drag marks that were seen in the lodge were consistent with that and in any case did not appear to have crossed the stone pit. I think it more likely that the burns were sustained at a time when the deceased was unconscious and supine in the lodge prior to his removal, again highlighting the dangers associated with an altered state of consciousness when participating in a sweat lodge.

8.6. Professor Byard suggests that there had been a critical delay in obtaining essential therapy for the deceased. Any situation involving a patient who is unconscious from any sort of insult will do better the quicker medical treatment is instituted. If the deceased could not be rehydrated orally, then he required access to an IV drip that in reality could only be administered professionally. He suggested that there were signs that Mr Cooke was already deceased by the time he was first seen by the volunteer ambulance crew from Leigh Creek. While it is not possible to conclude with certainty that if the deceased had been provided with earlier access to professional assistance he Exhibit 23a, page 238

would have survived, Professor Byard expressed the belief that had the deceased been provided with more timely access to professional intervention, his chances of survival would have been much greater than what they had been and that it was possible that he may have survived. I accept that evidence.

8.7. In my view the delay in seeking professional assistance of the kind that Professor Byard envisaged meant that the deceased was denied a proper chance at survival.

That delay was occasioned by a number of factors. The location of the deceased’s collapse was remote and there was no plan in existence that could deal with any emergency such as the one that arose. For instance, there was no evidence that there was any proper means of communication that would have enabled the group to make contact with emergency services. As far as is known nobody possessed a mobile phone that was capable of communicating with the outside world, given that in the location in question there was no coverage available to conventional devices. I was told that there was a CB radio located in one of the vehicles at the scene, but there is nothing to suggest that in that location it could have enabled communication with anyone of significance. There is no evidence that any attempt was made to utilise the radio. Secondly, there was no plan as to what would be required in order to evacuate someone from the location in the event of an emergency and no plan in existence as to where a person could be taken in such an emergency. Thirdly, although there may have been some knowledge of first aid on the part of some of the group, there was no evidence that any of that knowledge was put to good use. Mr Jarvis told me that he had no knowledge of the symptoms of overheating or dehydration nor had any knowledge about the treatment or resuscitative measures for the same. He did not think that anyone else in the group had any such knowledge either. You would think, however, that anyone with even a rudimentary grasp of first aid would have recognised the need for medical assistance in an unconscious and unrousable human being. The fact that the deceased was wrapped in blankets very much suggests that nobody there had a clue as to what should happen to the overheated patient in the first instance. However, much of the above tends to pale somewhat when it is remembered that the one thing that really stood in the way of the deceased obtaining timely medical help was the belief system entertained by the group that held that the deceased was simply experiencing some kind of detachment from his physical being from which detachment he would in due course return. It is my view that this was the critical factor in the deceased’s demise.

8.8. Professor Byard made one additional and worrying observation. He told me that evidence would suggest that one of the aims of some persons who use sweat lodges is the actual alteration of their mental state - to a point where they believe that they are astrally travelling or having visions, and that this is induced by hyperthermia. This puts them in a precarious situation, especially where, as was the case here, alternate therapies are thought to have the ability to bring them back if something untoward occurs. It is a matter of some concern that in his evidence Mr Jarvis confirmed what Professor Byard was talking about. The following passage of evidence occurred in Mr Jarvis’ examination: 'Q. How would they go about achieving an out-of-body experience in a sweat lodge.

A. Well just by - intensive lodges are like that.

Q. What do you mean by intensive lodges.

A. Well some people make it as hot as possible.

Q. In order to achieve an out-of-body experience.

A. In order to achieve some connection with spirit and you know, that's - that is exactly that, out-of-body.

Q. So how do you know in those circumstances then, whether what the person is really trying to achieve is a level of unconsciousness, rather than an out-of-body experience.

A. You don't.

Q. Do you accept now that people who have experienced out-of-body experiences in sweat lodges have essentially been suffering from a marked reduction in their conscious state.

A. I can accept that, yes.' 29 Mr Jarvis also referred to the existence of the endurance lodge the aim of which is to deliberately subject the body to heat for as long as possible in order to push oneself to the limits of one’s physical endurance. The undesirability of such exercises, especially those taking place in the kind of circumstances that prevailed, here is manifest.

Transcript, page 111

9. The evidence of Ms Blackmore 9.1. The approach to the manner in which these activities were administered and to the obvious crisis that had developed here is to be contrasted to the approach to safety that is adopted by SOTEMS as described in evidence by Ms Prudence Blackmore.

SOTEMS is an Australia wide organisation that takes its inspiration from the spiritual practices of the Native Americans and which provides organised opportunities for the undertaking of vision quests and sweat lodges for devotees and others so inclined.

9.2. It is no part of this Inquest’s function to give its seal of approval to this entity or its practices or otherwise to endorse its product, but it is worthwhile recording the safety measures that the organisation says it adopts, and has adopted all along, in relation to the welfare of participants in sweat lodges, measures of which there was little evidence as far as the activities of the group of eleven were concerned. I adduced this evidence if for no other reason than to bring into sharp focus how utterly unnecessary this death was and how it may have been prevented by the kind of measures described by Ms Blackmore.

9.3. Before describing these measures in any detail, it should be noted that Ms Blackmore is a clinical psychotherapist having qualifications as a registered psychiatric nurse.

Ms Blackmore candidly acknowledged that the whole realm of vision questing and its connected activities attracts more than its fair share of strange people. Ms Blackmore also referred to the ‘quackery’ associated with these activities but nevertheless insists that there are reputable people running vision quests as well. While there is an obvious air of mysticism surrounding the activities of SOTEMS, and while sweat lodges run by her organisation are certainly designed to encourage people to access alternative levels of understanding of the contents of their day to day lives, the more extreme belief systems that involve out of body experiences of the kind described by Mr Jarvis and the like are not embraced by Ms Blackmore or her associates.

Certainly, SOTEMS deprecates the concept of endurance lodges or the pursuit of unconsciousness by the subjection of the body to heat. Ms Blackmore said that any level of unconsciousness arising from the use of a sweat lodge would be treated by her organisation as a medical emergency for which the necessary professional assistance would be sought. I was reassured by Ms Blackmore’s acknowledgment that there is no evidence that drumming, chanting, smashing pipes or burying feet in soil provides any discernible therapeutic advantage to an unconscious human being.

9.4. Ms Blackmore described a raft of safety measures that are practised by her organisation that in the main simply reflect common sense. She correctly identified a duty of care that people who facilitate sweat lodges owe to their participants, including even the experienced, and was correct to observe that safety is the paramount consideration. The emphasis appears to be on preparation, monitoring and access to professional assistance in the event of an adverse incident.

9.5. Ms Blackmore referred to the vetting of aspirants in so far as an assessment is made of their physical and emotional suitability to participate in a sweat lodge. For instance, those with a clear and present psychiatric issue or who possess a background of the same would be excluded, as would persons who describe certain physical illnesses and conditions.

9.6. The facilitators who conduct sweat lodges on behalf of the society are trained in the conduct of the ritual and additionally are trained in first aid by Red Cross, with their qualifications being updated on a regular basis. They are not permitted to run a sweat lodge until they have undergone the required training. Essential attributes for a facilitator are leadership qualities, intelligence and awareness. The facilitators are actually present within the sweat lodges at the time they are conducted and they monitor the physical and emotional well being of the participants, looking for any adverse signs such as alteration in conscious state, respiratory or other distress.

Novices are seated next to the door of the lodge and next to the facilitator. In addition, a close eye is said to be kept on temperature within the lodge and on the time in which participants are in the lodge and on appropriate ventilation. The people who run their expeditions monitor the participants’ daily intake of fluid.

9.7. SOTEMS does conduct sweat lodges in remote locations. However, mobile phones that are capable of operating in locations where conventional phones are not are regarded as essential equipment. They also possess a radio that is capable of communicating with a person situated in a substantial town such as Alice Springs.

9.8. The measures described above seem to be in contra distinction to what transpired during the events with which this Inquest is concerned, events that in my opinion were characterised by fecklessness at an astonishing level. If measures such as those described by Ms Blackmore had been in existence that morning there is no guarantee that the unfortunate outcome here would have been different, but there is good reason

to suppose that it may have. The one factor that could possibly have changed the outcome was a timely and sensible recognition of the fact that from the time Mr Cooke was removed from the sweat lodge he was desperately ill. It is a truly remarkable feature of this case that not one person out of the eleven was able to draw that inescapable conclusion until it was too late.

9.9. It is worthwhile observing that Mr Jarvis has not conducted a sweat lodge since the one involved in this Inquest. When drawn as to the reason for this, the following exchange took place: 'Q. Did you form the view after this incident that there was something inherently dangerous about this practice that perhaps has made you rethink the wisdom of it.

A. I’d say yes. I have to say that it made me think again, you know.' 30

10. Recommendations 10.1. Pursuant to section 25(2) of the Coroner’s Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest.

10.2. I would have had no hesitation in recommending that the practice of conducting sweat lodges be regulated in some way if a sensible method of so doing was readily apparent. However, it is a matter that the authorities should perhaps consider.

Certainly in my view the practice should be discouraged, especially in remote areas and these findings should serve as a warning to those minded to conduct or otherwise become involved in sweat lodges.

10.3. However I do make the following recommendation.

10.4. That the Department of Health and any other relevant authority issue public advice as to the use of sweat lodges and in particular: a) as to the dangers associated with exposure to high temperatures for prolonged periods in a confined space, and; Transcript, page 60

b) as to the dangers associated with the practice of sweat lodge rituals in remote areas that have limited access to communications and medical facilities; c) as to the need for all participants to understand that any medical emergency requires standard urgent medically supervised and monitored treatment; d) as to the need for adequate communication, knowledge of first aid and treatment for heat related illness and the recognition of symptoms of the same and the need for a proper plan for the evacuation of an unwell person in the event of an emergency; e) as to the need for care to be taken in the selection of co-participants in sweat lodges; f) as to the need for care to be taken in assessing the character and antecedents of persons who apparently hold positions of influence in the conduct of sweat lodges; g) as to the need for care to be taken in assessing the belief system of the persons with whom they participate in sweat lodges.

Key Words: Sweat Lodge; Dehydration; Public Warning In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 8th day of June, 2007.

Deputy State Coroner Inquest Number 15/2007 (3315/2004)