Shayne Anonson of Priddis, Alta., was admitted to Rockyview Hospital suffering from alcohol withdrawal and suicidal thoughts in February 2010.
A doctor determined the 44-year-old had to be treated in a medical unit before he could be placed in a psychiatric ward.
A fatality inquiry heard that other staff later talked to Anonson about the possibility he might be discharged and he became stressed.
He was then found hanging from a belt in the bathroom of his hospital room.
The province has since created a policy about caring for suicidal patients, but the inquiry judge thinks it needs to include instructions that staff communicate any risk changes and increase monitoring if needed.
"Several witnesses observed and charted Mr. Anonson's reaction to the discussions introducing discharge planning. His responses all indicated that he felt increased stress," wrote Judge George Gaschier.
"There was no evidence that his reactions and these observations led to an increase in level of observation or that any change in the level of observation was considered. There was no evidence that any of the persons who noted Mr. Anonson’s reaction made such a recommendation or had a process to do so."
The judge also recommended the province correct some confusion about respecting patient confidentiality.
Hospital staff testified that they thought they could only ask patients about whether they had family support if the patients brought up the subject first. Gaschier said it was obvious Anonson would have needed to access community support services if he was discharged.
"To avoid discussion of the possible involvement of family, unless and until the patient inquires if family may have a role, is an abdication of care."