It is clear Stanley Robillard should have never been released from a Saskatoon hospital three years ago.
What remains unclear is why he was.
At a coroner’s inquest into the death of the 46-year-old man Wednesday, three Saskatoon police officers testified they believed because of Robillard’s level of intoxication and the fact he was suffering from a head injury, he was unable to take care of himself.
Nevertheless, Robillard was released from St. Paul’s Hospital on July 15, 2010 after waiting 90 minutes in emergency and never being seen by a doctor or nurse.
Robillard had said he did not want medical attention and signed a release form relinquishing St. Paul’s from responsibility.
He was then taken to the Saskatoon detention unit where he remained until just before 6 a.m. the following day.
The inquest also heard Robillard had very limited interaction with police during his time there.
Cells are monitored on a regular basis by commissionaires but they do not have the authority to enter these cells – something only a special constable or sergeant on duty can do.
Video evidence shows Robillard lying face down in his cell with little movement from his time of arrival until he stopped moving altogether around 5:45 a.m.
At this time, 911 was called and staff tried to resuscitate him but to no avail.
Robillard was later pronounced dead at Royal University Hospital around 6:42 a.m.
Since 2010, the Saskatoon detention unit now has a paramedic on staff around the clock.
Testimony at the inquest is scheduled to wrap up Thursday morning with two witnesses remaining.
The six-person jury will then deliberate on recommendations in the afternoon.