An inquest into the death of Stanley Robillard has concluded that he died accidentally of blunt force trauma to the back of the head, with alcohol as a contributing factor.

Robillard was arrested three years ago for public intoxication in Saskatoon and later found unresponsive in a police detention cell. The 46-year-old died after being transported to Royal University Hospital.

The inquest also heard testimony that Robillard had earlier been to the emergency room at St. Paul's Hospital and had checked himself out. He had not seen a doctor. The Saskatoon Health Region's head of emergency services, Dr. James Stempien, testified that the system failed Robillard.

Among them, that hours be increased at City Hospital's emergency department, and in minor emergency clinics. And also:

• Patients classified as 1, 2 or 3 on the Canadian Triage and Acuity Scale have their vital signs checked more frequently.

• The triage process be eliminated or bypassed when a patient is classified as CTAS 1, 2 or 3.

• In shift changes, briefing on the status of patients in triage be improved.

• Information sharing between police, ambulance and hospital staff be improved regarding severity of injuries.

• The paramedic position at the detention centre be made permanent.

• The brief detox unit be expanded.

• Emergency departments be staffed with more doctors during peak times.

• There be a public awareness campaign about treatment options in minor emergency clinics.

• Health care improvements be audited more frequently, with measurable results and follow-up.