Full text of final report on listeriosis outbreak
By Sheila Weatherill
By Sheila Weatherill
July 23, 2009, OTTAWA – The final report of Sheila Weatherill, the independent investigator of the August 2008 listeriosis outbreak, has been released, and the full text can be downloaded here.
The report represents the conclusion of Weatherill's six-month long
investigation into the outbreak that cost 22 Canadians their lives. The report was submitted to the Minister of Agriculture and Agri-Food on
"Ensuring the safety of our food supply is one
of government's most important responsibilities," said
Weatherill. "My goal was to provide Canadians with answers about how
and why this outbreak occurred and to make recommendations that will
help to protect all consumers from future outbreaks or optimize the
response if they do arise."
Weatherill was appointed by the prime minister in
January. In the process of her investigation more than 100 key
individuals were interviewed or met, including affected family members,
representatives of industry and labour, and officials from all levels
of government. The investigation received more than 400 comments from
Canadians through the investigation's website and reviewed millions of
pages of documentation. The investigation also received advice from a
group of experts made up of respected Canadian and U.S. food safety and public health advisors.
"I learned that reviewing the outbreak in hindsight allowed me to
see the sequence of events that led to the outbreak and to identify
steps that could have been taken," Weatherill said. "I heard,
repeatedly, that if people had only known or recognized then what they
know now, these events may have evolved differently. Despite these best
efforts and insights, 22 lives were lost," she added.
The investigation identified four broad categories where improvements need to be made. There must be:
- more focus on food safety among senior officials in both the public and private sectors;
- better preparedness for dealing with a serious foodborne illness with more advance planning for an emergency response
- a greater sense of urgency if another foodborne emergency occurs;
- clearer communications with the Canadian public about listeriosis
and other foodborne illnesses, especially at risk populations and
"Canada's food safety system is made up of a complex set of safety
laws and regulations administered by a network of federal, provincial
and local agencies," Weatherill said. "My report recommends that both
regulators and business place safeguarding consumers at the centre of
their consciousness and collective actions."
After in-depth analysis and advice from food safety and public
health experts the independent investigator made 57 recommendations for
improvements to Canada's food safety system. The recommendations
- the safety culture of food processing companies;
- the design of food processing equipment;
- government rules and requirements for food safety;
- the need for food service providers to adopt food safety practices aimed at vulnerable populations; and
- government's capacity to manage national foodborne illness emergencies.
"Some of our country's most vulnerable people lost their lives to
this tragedy," concluded Weatherill. "It is my hope that timely action
will be taken to respond to this report in order to prevent a similar
tragedy from ever occurring in this country again."
Weatherill is also recommending to the Minister of Agriculture and
Agri-Food to report back to Canadians within two years on the status of
the implementation of her report.
The work of the Investigation has been complemented by the important
work of the House of Commons Agriculture Subcommittee on Food Safety,
which has also examined many aspects of this critical matter.