Stanley Robillard of Prince Albert died on July 16, 2010, the day after an ambulance picked him up in the parking lot of a bar.
Autopsy results determined he died from a severe head injury after falling and hitting his head in the parking lot.
The inquest heard he was heavily intoxicated at the time, and a witness who saw Robillard fall said he was stumbling like he was drunk.
Don Brickner, a paramedic with MD Ambulance, testified Tuesday that Robillard had a large bump and a small cut on the back of his head.
He said it was difficult to determine whether his slurred speech and difficulty walking was a symptom of a concussion or intoxication.
Brickner said because of the fall, he assessed Robillard as needing urgent care upon arrival at the hospital.
In emergency at St. Paul's Hospital, it was an extremely busy night, and Robillard ended up waiting on a stretcher in a hallway for 90 minutes.
Brickner said he then transferred Robillard to the care of another paramedic to free up an ambulance.
Nicole Neufeld, a registered nurse at St. Paul's, said she marked him down as needing urgent care.
But she said she had to wait for a specific room in order to suture his head wound, and did not assess Robillard in the meantime.
Because he was not officially a patient, Neufeld said there was no policy requiring triage nurses to re-check a patient's vital signs when they are still in the care of paramedics.
In the end, Neufeld said she decided that Robillard did not need to be immediately seen by a doctor because it was "not a matter of life and death at that time."
When Donna Geiger took over the triage desk from Neufeld, she says she was told that Robillard had been drinking, fell and needed sutures.
Geiger says she doesn't remember getting any specific information about Robillard's head injury, including that he was possibly unconscious for up to four minutes after he fell.
Geiger told police about the long wait time, at which point she overheard Robillard tell an officer that he wanted to leave.
Since patients have the right to refuse medical care, Robillard signed himself out of the hospital and was taken to a police cell to sober up. He was found dead nearly six and a half hours later.
Although the inquest aims to come up with ways to prevent similar deaths, both nurses said improvements have already been implemented since Robillard's death.
Nurses are also now required to tell doctors if someone with an urgent rating is refusing medical care, with the hopes that a doctor will be able to speak with that person first.
Both Neufeld and Geiger said the policy was a direct response to Robillard's case.
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