Provincial court Judge Gordon Krinke also had harsh words in his inquiry report for the owner of Gringo's bar in Medicine Hat, which witnesses said has a steep set of stairs that are dangerous even for sober patrons.
The report, released Friday, said Stewart McAllister of Chorley, England, was stationed at CFB Suffield in southern Alberta when his training group was granted their first leave from the base on Oct. 23, 2008.
The inquiry heard McAllister had a blood alcohol level 3 1/2 times the legal limit after drinking at least 13 beers and a tequila shot that night.
Friends said the 20-year-old appeared fine and headed outside to have a smoke.
The inquiry heard poor lighting made the steep, wide stairs tricky to navigate and there were railings on the sides, but not down the centre. Old carpet on the stairs was torn and many people had tripped on them.
McAllister was about two-thirds of the way down when he lost his balance and struck his head on a concrete wall. He died five days later in hospital.
Witnesses said the soldier wasn't pushed or kicked and the judge ruled the death was clearly accidental.
Krinke said McAllister was ultimately responsible for the amount of liquor he consumed, but the judge added that bars are also obligated not to over-serve.
He recalled the testimony of one Gringo's employee who said the bar's greed for profits trumped monitoring alcohol consumption. And because drinks were sold from so many different parts of the bar, it was impossible for staff to keep track of how much people were drinking.
Another staff member, a waitress who exclusively sold shooters, told the inquiry she was under pressure to "sell, sell, sell."
Krinke also pointed out the provincial government made about $665 million in profit from alcohol sales the year McAllister died.
"Given that the income of all parties involved in the sale of alcohol is determined by the amount of alcohol served, there certainly is no economic motive to limit the consumption of alcohol," the judge wrote in his report.
"The only realistic means of ensuring that patrons are not over-served is through outside enforcement."
Krinke made nine other recommendations in his report, most of them encouraging the Alberta Gaming and Liquor Commission to develop policies so bars better monitor and limit alcohol consumption.
He also said the sale of shooters should be limited, as well as the number of serving areas within bars.
Jody Korchinski, a spokeswoman with the liquor commission, described the soldier's death as tragic and said the organization is committed to responsible alcohol service.
"We certainly will be taking a close look at this report as we go through our ongoing reviews of our liquor policies," she said.
She said since the death, it has become mandatory for all servers to complete a training program that helps them recognize when patrons become intoxicated.
Officials conduct about 34,000 inspections each year, she added.
Korchinski said officials did investigate Gringo's after the death but no charges were laid.
The bar, located in a hotel basement, has since been renamed Temptations. The judge's report said a safety inspection in 2010 showed new management installed a required centre railing on the stairs.
— Chris Purdy in Edmonton