Canadian food officials were made aware of serious problems in the inspection system that could threaten public safety three years before an outbreak of the food-borne illness listeriosis that has been linked to 18 deaths, according to an internal report by the Canadian Food Inspection Agency.

A food inspector in Montreal takes cheeses that may have been cross-contaminated with listeria away to be destroyed. (Peter McCabe/Canadian Press)

The 2005 report, titled the Food Emergency Response Review, documented problems with some of the CFIA's food inspection procedures, delays in issuing public warnings about potentially dangerous food products, and a lack of followup after problems were identified.

"The safety of food in Canada is somewhat unpredictable," Rick Holley, professor of food microbiology and food safety in the department of food science at the University of Manitoba in Winnipeg, said after reading the report. "There should be a reasonable level of confidence that the food that we eat is not going to make us sick."

The inspection agency's review was conducted from January to March 2005 by the CFIA's corporate planning, reporting and accountability branch. CBC News obtained the review using the federal Access to Information Act, as part of a joint CBC News/Toronto Star investigation into food safety.

The reviewers were trying to answer three key questions: who is responsible for what when the agency recalls bad food, what followup is conducted once the food has been recalled, and how do investigators assess risk?

The blunt review concluded that there was "no clear policy on when a recall requires public warning," that there was no "common understanding of what is meant by recall followup," and that "processes and strategies do not appear to be in place for systematically dealing with repeat [recall] offenders."

Many of the concerns highlighted in the 2005 review were raised in two previous internal reviews dating back to when the agency was first established, in 1997. Canada's auditor general also expressed similar concerns in 2000.

It's difficult to determine whether changes have been made to the CFIA's procedures as a result of the report, as agency staff have refused to be interviewed on the subject by CBC News and the Toronto Star.

CFIA food inspectors say problems still exist, according to Bob Kingston, president of the Agriculture Union of the Public Service Alliance of Canada, which represents inspectors. After circulating the internal review to union members, Kingston said one inspector wrote to him in an e-mail that, "Industry just calls a voluntary recall and no enforcement action is taken. We have no teeth to speak of."

Kingston said a second inspector wrote in another e-mail: "If a recall is deemed ineffective, food safety will ask for the recall to be repeated and a letter is written.… Some inspectors may have time to do followup inspections, but mostly they move on to the next complaint/recall."

Mike McBane, national director of the public health-care advocacy group the Canadian Health Coalition, called the 2005 report "shocking."

"No clear policy on a recall. Can you imagine? An emergency response program that has no policy on recalls?"

Prime Minister Stephen Harper announced on Sept. 3 that the government would conduct an investigation into the recent listeriosis outbreak, which was tied to meat from a Maple Leaf Foods plant in Toronto. The report is due before March 15, 2009. Investigators will not draw conclusions nor make recommendations about civil or criminal liability of individuals or organizations.

Critics such as Amir Attaran, the University of Ottawa's Canada Research Chair in law, population health and global development policy, who has read the 2005 CFIA report, are calling for a full government inquiry into the outbreak.

David McKie, Susanne Reber and Laurie Graham contributed to this report