Coroner's Finding: COOKE Rowan Douglas

Contributing factors

• prolonged exposure to high temperatures in confined space
• dehydration prior to ceremony
• delayed recognition of medical emergency
• delayed seeking of medical assistance
• inappropriate first aid (wrapping in blankets)
• belief system interpreting unconsciousness as spiritual experience
• remote location with limited access to communications and medical facilities
• lack of emergency planning
• lack of first aid knowledge
• absence of medical supervision

Coroner's recommendations

1. That the Department of Health and any other relevant authority issue public advice as to the dangers associated with exposure to high temperatures for prolonged periods in a confined space
2. Public advice regarding dangers of sweat lodge rituals in remote areas with limited access to communications and medical facilities
3. Public advice regarding the need for all participants to understand that any medical emergency requires standard urgent medically supervised and monitored treatment
4. Public advice regarding the need for adequate communication, knowledge of first aid and treatment for heat-related illness, recognition of symptoms, and a proper plan for evacuation of an unwell person
5. Public advice regarding the need for care in selection of co-participants in sweat lodges
6. Public advice regarding the need for care in assessing the character and antecedents of persons who hold positions of influence in sweat lodges
7. Public advice regarding the need for care in assessing the belief system of persons with whom participants engage in sweat lodges
8. Consideration by authorities of whether regulation of sweat lodge practices is feasible
9. Discouragement of sweat lodge practice, especially in remote areas