http://www.courts.sa.gov.au/images/Graphics/Coat_of_Arms.jpg> 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn1>
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. 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn2>
. 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.
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 2004[3]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn3>
. 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 2004[4]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn4>
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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn5>
. Others were involved in the preparation and heating of the stones
and in the delivery of the stones 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn6>
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 introduced[7]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn7>
. 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 introduced[8]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn8>
. 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 the heat in a sweat lodge ‘as I am in a different
place’[9]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn9>
, 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 statement[10]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn10>
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.
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 mercury[11]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn11>
. 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
feather[12]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn12>
. He then opened the door and states that he noticed that the deceased
‘appeared to be unconscious’[13]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn13>
. 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, 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn14>
. 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
2004[15]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn15>
, 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 time[16]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn16>
. Mr Kenneth Gifford who provided a statement dated 4 November
2004[17]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn17>
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 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn18>
, 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn19>
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 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 pagers[20]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn20>
. 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 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
experience[21]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn21>
. 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 moving[22]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn22>
. He seems to attribute this partial revival to his drum banging. Mr
Asfar’s lack of recall of the events after his collapse means 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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn23>
Messrs Myers and Gifford then drove to the homestead and returned with
Mr Doran.
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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn24>
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 evidence[25]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn25>
. 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.
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 output[26]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn26>
.
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 co-written 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.
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]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn27>
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 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
hydraÂtion. People with underlying significant cardiovascular
disÂease, certain medications, and recent heavy alcohol consumpÂtion should
be discouraged from participating in such activities.' [28]
<http://www.courts.sa.gov.au/courts/coroner/findings/findings_2007/cooke.finding.htm#_ftn28>
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 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.
