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. 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.' Recommendations 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. 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. However I do make the following recommendation. That the Department of Health and any other relevant authority issue public advice as to the use of sweat lodges and in particular:
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. 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.' Recommendations 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. 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. However I do make the following recommendation. That the Department of Health and any other relevant authority issue public advice as to the use of sweat lodges and in particular:
COOKE%20Rowan%20Douglas.docx