ST. THOMAS, Ont. - The inquest into the death of a 47-year-old inmate at London’s Elgin-Middlesex Detention Centre (EMDC) has come out with 11 recommendations for change.

Michael Fall died in July of 2017, inside a 24-unit cell range. His cell mate had immediately called out for help, after Fall overdosed on fentanyl.

It would take six minutes before the overdose antidote, naloxone, was available at his side.

“His cell mate can be seen screaming in the window, that someone arrive with naloxone,” Kevin Egan, the lawyer representing Fall's family, said after the inquest verdict.

Egan says the jury took many of the recommendations lawyers for all sides had presented.

He points to several key ones, which he believes will bring about change, if implemented.

Among them, a call for all correctional officers – not just supervisors – to carry naloxone.

“Frankly I was surprised, given the number of deaths we've had at EMDC, that hadn't already become policy. But, that just makes good sense. If they can have it, they should."

The inquest is also recommending guards are briefed on which inmates have recently been caught with contraband drugs.

The list then turns to recommendations focusing on the inmates themselves, including a recommendation counselling provided, by an outside party, to help inmates deal with the aftermath of a death.

While Egan attended the inquest's conclusion Friday, on behalf of Michael Fall, his family was not present.