A Saskatoon jury has concluded that Kevin Umpherville's overdose death at the Saskatoon Correctional Centre was accidental and has recommended changes to the poison control system that doctors use so that similar deaths can be prevented in the future. 

A jury at the inquest into 22-year-old Umpherville's death heard this week that an emergency room doctor at Royal University Hospital sent Umpherville back to jail with a lethal dose of methadone still in his system.

Kevin

Kevin Umpherville (Facebook)

He was sent back to his cell after the doctor consulted with the Poison and Drug Information Service in Alberta. The inquest heard that the doctor was given incorrect information. 

The jury is now recommending changes to the way questions about drugs are handled at the poison control centre.

Umpherville was twice found unresponsive

Umpherville had been arrested and charged in connection with a domestic dispute on Dec. 25, 2015.

On Dec. 30, 2015, he was discovered limp and face down on his bunk, with a purple hue to his complexion.

Umpherville was rushed to hospital and spent 10 hours there before he was returned to the jail that same day.

The next morning, he was again found unresponsive and was rushed back to the hospital. His family took him off life support two weeks later.

The inquest concluded Umpherville died from complications resulting from his overdose.

They also ruled that his death was accidental.