A Manitoba judge is calling for changes to a section of a homeless shelter commonly called the drunk tank following a man's death in November 2009.
Judge Dale Schille says people should only be discharged from the 20 beds at the Main Street Project in Winnipeg after being examined by a paramedic.
Schille also says the facility needs better video surveillance and possibly needs to expand to meet demand.
Schille has issued an inquest report into the death of Douglas Leon Sanderson, a man who was intoxicated and had hit his head at least twice at a downtown hotel bar.
Sanderson refused a request by paramedics to go to hospital, but agreed to go to the Main Street Project, where he fell at least two more times and struck his head.
Sanderson was taken to hospital and died after unsuccessful surgery to relieve swelling of his brain.
The inquest report says the drunk tank is very busy during peak times, and staff should have easier access to surveillance video so they can keep better tabs on clients.
The judge said it became clear that Sanderson suffered a brain injury at some point — either prior to or after his admission — but paramedics would not have detected it right away.
"The bleeding had not progressed to the point that vital signs were impacted by symptoms," Schille wrote.
"It appears that only complex diagnostic equipment such as a CT scanner could have confirmed the presence of subdural brain bleeding."
Staff had tried to dismiss Sanderson several hours after he was admitted, but he fell and was taken back to a room. Later, he fell from a sitting position, hit his head again, and was taken to hospital where he died.
The judge said staff may have felt pressure to release Sanderson to make room for others at the busy facility.
"Currently, it is not uncommon during peak periods to have police vehicles lined up down the street with intoxicated persons awaiting admission. The current ... facility consisting of 20 beds does not have adequate capacity to meet demand during peak periods."
The judge said the Main Street Project should talk to municipal officials and police about possibly expanding the centre.
He also noted the facility has already made several changes, including having more staff on hand. There are also new policies to position intoxicated people so that they have a much lower chance of falling.