A sheriff has called for an improvement in the way prisoners are monitored by police after the death of a man in a cell in Perth.
George McLellan died in police custody in Perth
A fatal accident inquiry has concluded George McLellan's death from drink and drugs in 2005 could have been avoided.
Sheriff Robert McCreadie QC now wants a Scotland-wide system of caring for vulnerable people detained by police.
A national review of the health and medical services provided for police custody has been ordered.
Sheriff McCreadie's report also recommended a number of changes to Tayside Police procedures which "might prove to be a lifesaver".
The fatal accident inquiry heard Mr McLellan was taken to police headquarters in Perth following a disturbance at a pub in Crieff on 23 December 2005.
The chronic alcoholic was supposed to be checked every half hour for a distinct verbal response after being classed as highly vulnerable.
He slipped into a coma and died in the early hours of Christmas Eve.
The fatal accident inquiry heard that vital information about his condition had not been passed on during a staff handover.
He was checked once in a 90-minute period before his death, and staff accepted grunts as answers to their questions.
Sheriff McCreadie stressed that the ultimate cause of Mr McLellan's death was drink and drugs and he had found no systemic defects in Tayside Police procedures.
However, he said "the reasonable precautions whereby his death might have been avoided" were a proper handover between duty officers and "timeous" visits to vulnerable prisoners.
He also raised concerns about weekend staffing levels in Perth, staff training and the force's Standard Operating Procedure, which he claimed was not written in plain English.
Sheriff McCreadie called for a Scotland-wide system for the care of persons in police custody, which would include monitoring by medically qualified personnel and the availability of life-saving drugs and medical equipment in police stations.
Tayside Police said procedures had already been updated since Mr McLellan's death.
A spokesman said: "It is acknowledged that a number of recommendations for consideration by the force have been made by the sheriff and many of these have already been implemented following our own internal review following the incident.
"The remainder will now be considered as a matter of priority and any changes necessary implemented at the earliest juncture.
The Scottish Executive said that a review into police custody had been ordered as a result of an increasing number of prisoners with medical and dependency issues.
A spokesman said: "Every police force takes seriously the care needs of those held in their custody and this government is working with Acpos at a national level to review the range of healthcare and forensic medical services provided in police custody settings.
"We expect the review to last several months and a plan will be developed to ensure that appropriate services can be provided in police custody settings throughout Scotland."