OTTAWA - A report into last summer's listeriosis outbreak has found a litany of problems behind the crisis that claimed 22 lives, including a weak response by the federal government.

Investigator Sheila Weatherill's sweeping investigation, released Tuesday, found a confluence of events contributed to what was one of Canada's worst food-borne illness outbreaks.

Among the findings:

-Federal meat inspectors assigned to the Maple Leaf Foods plant in Toronto where the outbreak started were "stressed" over having to oversee several other meat-processing plants.

-Government officials were also slow off the mark in responding to the outbreak after it started last July.

-The team that assesses health risks within Health Canada was short-staffed over the summer, "leaving gaps in coverage during the response to the emergency."

-The federal government was slow to communicate with the public and didn't keep up those communications long enough.

-There wasn't a single point person to deliver the government's message, leading to "a fragmented approach and seemingly inconsistent message."

The report makes 57 recommendations to help prevent another outbreak.

It says Canada's chief public health officer should be given a greater role during outbreaks of food-borne illnesses.

Meat companies should also be required to tip the federal government to any suspected health threats. And plants that routinely test positive for bacteria or represent a higher risk should be tested more frequently than others.

The report also recommends that manufacturers design easy-to-clean meat-processing equipment that limits the spread of bacteria.

The document does not include findings of criminal or civil liability.

Weatherill's team conducted more than 100 interviews and amassed some five million pages of information during a six-month probe, which was ordered by the federal government.

Twenty-two people died and hundreds more fell ill after eating meats traced to a Maple Leaf Foods plant in Toronto.

The company apologized and agreed to pay up to $27 million to settle class-action lawsuits.

Maple Leaf has also instituted more rigorous testing for the Listeria bacteria in plants producing ready-to-eat meat.

Company president Michael McCain told a news conference in Toronto that the company favours the Canadian Food Inspection Agency getting more resources, as well as more government regulations around food safety.

Agriculture Minister Gerry Ritz said the federal government will not compensate the families of listeriosis victims.

The government's responsibility to those affected by the deadly bacterial outbreak is to create a better food-safety system, he told a news conference.

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