The listeriosis outbreak that killed 22 Canadians and sickened dozens more was complicated by several factors, including insufficient focus on food safety, lack of understanding about which governmental jurisdictions were responsible, and inadequate communica-tion to the public, an independent investigator said yesterday.

Sheila Weatherill released the 156-page report — the result of a six-month investigation — to a press conference in Ottawa yesterday.

“Twenty-two lives were lost,” said Weatherill, who was appointed by Prime Minister Stephen Harper to investigate the circumstances surrounding the outbreak, which led to the recall of 191 meat products produced by a Maple Leaf Foods plant in Toronto.

“These individuals, mostly elderly and at risk of infections, put their faith in Canada’s food safety system, expecting it to protect them,” she stated. “Their faith, and that of all Canadians, was shaken.”

The report stated that the average age of people who died in the incident was 76 and that 80 per cent of those who developed listeriosis lived in long-term care homes or were admitted to a hospital that had served the contaminated food.

Forty per cent of the people who contracted the disease died, she said.

“Last summer’s outbreak was rare,” said Weatherill, but the risks of foodborne illness are on the rise and will only intensify in the future, she added.

The report, which includes 57 recommendations, grew out of 5.8 million pages of information as well as hundreds of interviews with representatives of industry and labour and the families of those who died.

Weatherill said she “heard repeatedly that if people had known what they knew now, events might have evolved differently.

“I think the main message we heard was that people didn’t realize who was vulnerable and which foods to avoid,” said Weatherill.

Recommendations included requiring all federally registered meat processors to disclose any threat to food safety occurring in their premises to the Canadian Food Inspection Agency in a timely manner; and that Canada’s chief public health officer should be given a greater role during outbreaks of foodborne illnesses.

“Prevention is the most important tool,” she said.

Weatherill “did not see bringing criminal or civil charges,” she said.