A fatality inquiry into the death of Edmonton inmate Vincent Beaudry found that "closer police attention" may have prevented the 2006 death at Edmonton police headquarters.
Beaudry died in police custody on June 29, 2006 after being arrested for aggressive panhandling.
The report says Beaudry was homeless, addicted, and mentally ill, and died because of prolonged drug and alcohol use.
The report found there was sufficient evidence that Beaudry was ill and had a medical assessment of Beaudry been ordered, his death may have been prevented.
In all, nine recommendations were made in the report, five of which have already been implemented.
