A "void in leadership" within the federal government during last summer's deadly listeriosis outbreak came after company officials and over-worked meat inspectors failed to identify a persistent listeria problem at the Maple Leaf Foods plant, according to a highly critical report by an independent investigator.
No player in the listeriosis outbreak escaped criticism from Sheila Weatherill, who released her report Tuesday.
But Weatherill zeroed in on a "vacuum in senior leadership" among government officials at the Public Health Agency of Canada and the Canadian Food Inspection Agency that caused "confusion and weak decision-making."
Despite the litany of problems flagged in the report, Agriculture MinisterGerry Ritz was quick on Tuesday to rule out any government compensation for the families of the 22 victims who died after consuming tainted meat. Maple Leaf has already apologized and agreed to pay up to $27 million to settle class-action lawsuits.
Calling it a "perfect storm," Ritz said "there is no one particular person or event that would have facilitated or stopped this situation."
"There are simply no easy answers," Weatherill told reporters before unveiling 57 recommendations aimed at preventing another outbreak, including a call for the public health agency to step up to the plate and assume the lead role during any future outbreaks.
"The investigation has made clear that much more could have been done to prevent this from happening in the first place and more to that point, much more must be done to make sure it doesn't happen again," added Weatherill.
While conceding listeria is a "virulent bug that is very difficult to pinpoint and even harder to keep in check," the report identifies decisions that "were not thoroughly thought through or executed" at every level, which contributed to the outbreak.
Weatherill also found senior executives at both Maple Leaf and the government agencies were not fully engaged in food safety issues, cementing a lack of urgency in the way they initially addressed the brewing crisis.
At the plant level, the report concludes company staff took action to destroy the bug whenever it was found, but they missed the "big picture" -- which was the "repeated pattern of presence of listeria on the same production lines several weeks after the problem was presumed to have been fixed."
Under federal rules at the time, the company was not required to flag these repeated positive tests to government inspectors.
Regular environmental testing and protective reporting are now required under new CFIA rules, reinforced in Weatherill's report and welcomed by Maple Leaf president Michael McCain, who on Tuesday said the report was "tough" on the company and "it ought to be."
"We thought at the time that we had a strong food safety program and we did not. Had we known then what we know now, we may have saved 22 lives," McCain said