The death of North American Palladium employee Pascal Goulet was ruled accidental by a coroner’s inquest on Friday. Goulet was killed at the company’s Lac des Iles mine near Thunder Bay, Ontario.

After three days of deliberation, coroner Dr. Michael B. Wilson wrote in his verdict, released Friday, that Goulet’s cause of death was “blunt force trauma to the head from a fallen rock.”

Goulet was discovered dead on July 10, 2014, 825 metres underground with a rock weighing as much as 500 pounds covering his head. He was found outside his loader in a “no-go” zone past a safe-limit sign painted on the wall.

Production supervisor Roger Thomas told the inquest that the only time a miner would be expected to leave his vehicle was if something had been broken. Evidence of a broken spray nozzle was found in the vicinity of the vehicle.

The five members of the coroner’s jury offered nine recommendations directed towards the provincial Mining Legislative Review Committee, the Ontario ministries of labour and community safety and correctional services, and North American Palladium to prevent a similar incident from happening again, such as creating “a subcommittee to develop a guideline for mining employers to use in order to determine the safe distance for workers to be located when working in a stope that has an open brow,” and creating regulation preventing workers from going past a safe-limit line on foot without permission from an area supervisor.

The two recommendations for North American Palladium called for the company to “ensure that medical staff are trained in critical stress management” and to “increase visibility of the brow with a one-metre wide visible paint strip across the brow.”

Related: How North American Palladium brought its Lac des Iles mine back from the brink

Melanie Goulet, Pascal’s wife, said she agreed with the jury’s recommendations.

“I think that all nine recommendations should be implemented,” she said in a statement. “And I hope to God that one of these recommendations can save somebody else’s life one day so no other family, no other children like my two beautiful daughters, have to live through what we’ve been living for the last four years.”

United Steelworkers (USW), the union Goulet was a member of, were also satisfied with the recommendations, but stressed that companies need to take steps to prevent accidents.

“There needs to be mechanisms in place to do the pre-emptive things, not the post-mortem things,” USW spokesperson Herbert Daniher said in an interview. “Vigilance is going to be a deterrent, and being proactive is where you're going to save lives.”

USW will also be lobbying the various agencies and the company to ensure the recommendations are implemented.

“It's not mandatory that they implement it, but we're going to do our best to make sure that they do,” Daniher said.

In a press release issued Friday, North American Palladium president and CEO Jim Gallagher extended his condolences to Melanie and the Goulet family.

“We will always mourn the loss of one of our own,” he said. “None of our employees should ever go to work and not get home safely to their families.”

The company states that it will be carefully reviewing all the jury’s recommendations, and will focus on incorporating them into its actions in the future.

According to data collected from the Workplace Safety and Insurance Board of Ontario (WSIB),  the number of no-lost-time injuries — when no time is lost from work except for the day of the injury — at Lac des Iles has risen since 2012, but time-lost injuries — where an injury results in time off, loss of wages or permanent disability — has fallen. Compared to the rest of the Ontario mining industry as a whole, Lac des Iles has fallen under the average amount of lost time injuries since 2014. The WSIB puts the mine at 0.45 injuries per 100 employees vs. 0.7 for the entire industry.

WSIB also states that 20 employees have been killed in Ontario mines since 2011.