A Maple Leaf Foods employee sprays a cleaning product inside the company's meat facility in Toronto last December. (Nathan Denette/Canadian Press)

Manufacturers should be required to design meat-processing equipment that is easier to clean and thus limits the spread of bacteria, says a newly released report on Canada's deadly 2008 listeriosis outbreak.

Improved equipment design was one of 57 recommendations in the report made public Tuesday after a six-month investigation headed by Sheila Weatherill, former CEO of Edmonton's Capital Health Region.

She also recommended a greater role for Canada's chief public health officer during outbreaks of food-borne illnesses, tipping the federal government to any suspected health threats, as well as more on-site inspections at meat-processing plants.

Weatherill's team conducted more than 100 interviews and sorted through 5.8 million pages of information during the probe, which was ordered by the federal government after last summer's bacterial outbreak, blamed for the deaths of 22 Canadians.

She said her team of investigators learned that in "hindsight, it's very much easier to see a sequence of events that led to the outbreak," linked to meat produced at a Maple Leaf Foods plant in Toronto.

"It was an event complicated by multiple jurisdictions and their constitutional relationships. It involved both the public and private sectors, and it also included the fast-changing world of science and technology," she said at news conference.

The investigation identified four broad categories where improvements need to be made. The report said there must be:

• More focus on food safety among senior officials in both the public and private sectors.
• Better preparedness for dealing with serious food-borne illness, with more advance planning for an emergency response.
• A greater sense of urgency if another food-borne emergency occurs.
• Clearer communications with the Canadian public about listeriosis and other food-borne illnesses, especially with at-risk populations and health professionals.

"The 2008 outbreak first emerged in Ontario and was therefore under provincial leadership," the report says. "At the outset, the outbreak was not considered a severe food-borne emergency. This led to a void in leadership in managing the crisis. It took close to three weeks before senior executives in all key organizations became fully engaged in the event."

Sheila Weatherill discusses her report on last summer's listeriosis outbreak on Tuesday in Ottawa. (Sean Kilpatrick/Canadian Press)

The report doesn't make findings of criminal or civil liability, but it says the federal government should review the training of its inspectors and look at inspection resources.

Federal Agriculture Minister Gerry Ritz said his government has already implemented some of the recommendations and will use Weatherill's report as part of its "roadmap" to further strengthen Canada's food safety system.

"For example, this government has re-established mandatory requirements for environmental testing for listeria, and for any positive results they must be reported to the CFIA [Canadian Food Inspection Agency] immediately," he said.

"Mandatory environmental testing and reporting had been cancelled [in 2005], so it didn't raise the red flags here that should it have," the minister said.

He said the government has also hired more food inspectors and increased the CFIA's "overall capacity."

Maple Leaf Foods CEO Michael McCain gave the report high marks for coming up with with "strong" recommendations for further improving the Canadian food safety system.

He also said it was a painful reminder of the factors that led to the tragedy.

"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," he said. "The report is tough in its findings on Maple Leaf and it ought to be. We don't protest our innocence, we accept the responsibility."

Last summer's outbreak was rare for Canada, Weatherill said.

"In 2008, we ranked fifth of 17 OECD [Organization for Economic Co-operation and Development] countries for food safety," she said. She added, however, that more needs to be done to better protect the food supply.