The inquest heard how Stanley Robillard was arrested for public intoxication after falling backwards and hitting his head outside a Saskatoon on July 15, 2010.
The next morning, the 46-year-old heavy equipment operator from the Muskoday First Nation was found unresponsive in a police detention cell.
Before he was taken to police cells, paramedics and police waited with Robillard in the emergency room triage area at St. Paul's Hospital for 90 minutes, but he didn't get any medical treatment.
Even though both a triage nurse and paramedic rated Robillard as "urgent" on the Canadian Triage and Acuity Scale, he was given a release form after a nurse overheard him say he wanted to leave.
The jury recommended the Saskatoon Health Region improve communication between nurses, paramedics and police officers when a patient is brought in to emergency.
The health region made its own recommendations in the wake of Robillard's death, and will compare them to those made at the inquest, said Sandra Blevins, vice-president of integrated health services.
"We'll correlate it to see if there's anything that we need to pick up on or address," Blevins said.
The jury also recommended more beds at Saskatoon's Brief Detox Unit, something Robillard's sister Celina Robillard was hoping would come out of the inquest.
While the process did help fill in some of the gaps about her brother's death, Celina said it was also frustrating because she felt it inaccurately portrayed her brother as an alcoholic.
According to an autopsy report, Robillard's estimated blood-alcohol level was between .04 and .05 when he fell.
"Sure he indulged every once in a while, but they're making it sound like that's all he did. That's not all he did. He worked, he provided for his family ... he loved the outdoors," she said through tears.
"He always put others before himself. He would make sure his family's needs were met before his own," said sister-in-law Melvina Goulet.
She said Robillard often worked away from home at dry camps, and had been working at a potash mine and living with his brother in Saskatoon at the time of his death.
Paramedics were told he had fallen three times and was possibly knocked unconscious. They were also aware of a bump on the back of his head about the size of a baseball.
Celina and Goulet believe health-care workers were treating Robillard for intoxication instead of the fatal head injury he sustained from his fall.
"And because they believed he didn't want to be there and he didn't want treatment, they had him sign a form. If he was five times the legal limit, how was he competent to sign a form saying he didn't want treatment?" Goulet said.
"The purpose of an inquest is not to find guilt, and nothing will ever bring Stanley back, but when people take away the humanity, then what do we have left?"
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