Stanley Robillard should have been seen by a doctor within a half hour of arriving at a Saskatoon hospital three years ago but it never happened.

Instead, the coroner’s inquest into the death of the 46-year-old man heard Tuesday he was released from St. Paul’s Hospital after waiting in emergency for an hour-and-a-half without ever being properly examined by either a doctor or nurse.

Nicole Neufeld, the admitting nurse who first saw Robillard when he arrived in hospital on July 15, 2010, testified she marked his file as urgent meaning he should have been seen by a doctor within 30 minutes.

Donna Geiger, one of the nurses who authorized Robillard’s release also told the inquest she never read his file or spoke directly to him.

She says her decision that Robillard was well enough to be discharged from hospital was largely based on a conversation she saw him have with a police officer where he appeared to be calm and “cognizant.”

Geiger adds a lack of available resources also played a role in the decision to allow Robillard to sign a waiver form authorizing his own release from hospital.

She told the inquest that he was becoming increasingly frustrated after waiting in emergency for 90 minutes and it would have likely been a few hours more before a proper room or doctor would have been available to examine him.

St. Paul’s has now changed its protocols so that if a patient is requesting to leave hospital and this is believed to be against their best interests, they must first see a doctor before being allowed to sign a waiver form authorizing discharge.

Earlier in the day, the inquest also heard from paramedic Don Brickner who was one of the first responders to attend to Robillard after he had fallen twice in the parking lot outside Toon Town Tavern.

Brickner says he felt the injuries Robillard had sustained from the falls were serious enough that he needed to see a doctor.

He adds a witness told him Robillard had “fallen back like a tree” and hit his head on the pavement.

Robillard refused immediate medical attention causing Brickner and his partner to call for police back up.

After being released from hospital around 11 p.m., Robillard died in Saskatoon police cells in the early morning hours of July 16, 2010 from head injuries sustained in these falls.