How did we approach this report?

The summer of 2008 will be remembered by many Canadians for the listeriosis outbreak that made national and international headlines - an event that, ultimately, claimed the lives of 22 Canadians and touched many more.

Hundreds of news stories and website blogs as well as 'lessons learned' reports have been written about the outbreak. Yet, despite the thousands of words used to describe these events, many questions remained unanswered - particularly for survivors and family members of those who died. This report is an attempt to fill that gap.

Before reviewing this document to find out who did what and when, it is helpful to recognize that the issues involved in the outbreak were complex. These issues involve the constitutional relationship between the federal and provincial governments in public health and food safety. They involve the mandates and legal relationships among three federal organizations, their provincial counterparts and food processors. Finally, they involve the complex world of science and technology.

This report examines the way these relationships played out during the 2008 listeriosis outbreak and the response of the various parties involved. It also focuses on ways in which government, industry and others with a role in food safety can work better in the future to reduce the risk that the tragic events of the summer of 2008 will be repeated.

About the Listeriosis Investigative Review

At the height of the nationwide recall of contaminated ready-to-eat meat products, on September 3, 2008, the Prime Minister announced an independent investigation into the events surrounding the 2008 listeriosis outbreak. On January 20, 2009, Sheila Weatherill was appointed by the Governor-in-Council to lead the Independent Listeriosis Investigative Review.

The Independent Investigator's mandate is to review the August 2008 listeriosis outbreak, focusing on all the meat products involved in the disease outbreak, and the subsequent recalls of foods, originally produced at Maple Leaf Foods' Bartor Road plant. Specifically, the Investigation was set up to:

• Examine the events, circumstances and factors that contributed to the listeriosis outbreak;
• Review the efficiency and effectiveness of the response of the federal organizations, in conjunction with their food safety system partners, in terms of prevention, recall of contaminated products, and collaboration and communication with their food safety system partners and consumers; and
  
• Make recommendations, based on lessons learned from that event and from other countries in terms of best practices, as to what can be done to enhance both the prevention of a similar outbreak occurrence in the future and the removal of contaminated products from the food supply.

This report represents the results of this Investigation.

Approach

The Investigation needed to be both methodical and systematic to ensure it explored the factors that played a role in the 2008 listeriosis outbreak to contribute to future policy decisions and/or to improve industry practices.

Expert advice

During the investigative process, advice was received from a group of expert advisors made up of respected Canadian and US food safety and public health authorities. The group was consulted on the approach and methodology used to guide the work of the Independent Investigator. The experts reviewed and commented on this report during its development.

In addition to scientists, external specialists from the medical, public health, food safety, long-term care, legal, communications and governance fields provided advice throughout the process to assist the progress of the Investigation.

Comprehensive review

To the extent possible, the investigative team considered all viewpoints and implemented necessary measures to be fair and balanced. Considerable effort was made to ensure this was both a comprehensive and inclusive process.

Forensic investigators and technology experts collected and analyzed in excess of 5.8 million pages of information received in both paper and electronic formats, including emails. They scanned and processed this information into a database used to search and target relevant information. This material established the key facts and assisted the Independent Investigator in formulating questions for interviews.

Much more than a paper exercise, the Independent Investigator also conducted more than 100 interviews with a broad cross-section of individuals having first-hand knowledge of the events. These included workers on the plant floor, executives, frontline public health and food safety workers, researchers and scientists, managers, deputy ministers and Ministers from the federal and provincial governments, representatives from consumer and industry associations and unions, and family members of those who died and whose lives were personally touched by the tragedy.

The Independent Investigator appreciates the significant cooperation received from those affected by the listeriosis outbreak, both directly and indirectly. Everyone who was asked to participate agreed to be interviewed. The Investigator received open and forthcoming information and advice.. It was clear that people wanted to provide information to be part of the solution.

A number of roundtables with food safety experts - drawn from industry, consumer groups, academia and government - were convened to learn more about the latest technologies and industry practices. Information sessions were also held with food processors, equipment manufacturers, grocers and others with valuable insights into food safety to learn of their experiences and to seek their counsel.

As valuable as the lessons learned from the events of 2008 are, as part of the Investigation we examined and obtained advice from experts into the experiences of other jurisdictions. Key best practices or alternative approaches to food safety are referred to throughout the report.

This work has been complemented by the important work of the House of Commons Agriculture Sub-Committee on Food Safety which has also examined many aspects of this critical matter. We also heard from many of the witnesses who appeared before the Sub-Committee, and we have taken account of what we heard from them and on occasion what they have said during the public hearings of the Sub-Committee.

Listening to Canadians

The Independent Investigator also reached out and listened to Canadians to consider their views and concerns. Many interested Canadians contacted her to express their positions on the issues being examined. The Investigator received hundreds of emails from private citizens. Many more visited the website to learn about the Investigation. From the time of its launch on January 23, 2009, the Listeriosis Investigative Review website averaged approximately 300 visits per week.

This level of interest reinforced a further consideration in preparing this document: the need to make it both understandable and accessible to a wide array of interested readers - from people affected by the outbreak to parliamentarians.

There are many potential audiences for this report. Given the complex nature of the subject matter, some of the information contained in this report may appear technical to people unfamiliar with the terminology used, especially scientific, medical and legal. Translating the full range of information gathered through this Investigation in a clear and straightforward way that all Canadians can understand has been an overarching goal in preparing this document.

In order to follow the report's findings, it has been structured to provide answers to the key questions many Canadians have about the 2008 listeriosis outbreak and what can be done to prevent a similar incident in the future. Our aim has been to lay out the information in a way that chronologically and logically explains the chain of events which culminated in the outbreak, follow-up by the actions in the aftermath of the event, as well as the areas that continue to require attention and action.

The Independent Investigator is confident that this report will assist in answering Canadians' questions about what happened during the 2008 listeriosis outbreak, how it could have happened, and what should be done to make sure it never happens again.

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"Before the summer of 2008, most Canadians had probably never heard of listeriosis..."