Sheila Weatherill did her job and did it well. She always does.
The head of the Independent Listeriosis Investigative Review provided a thorough cataloguing of the failings that left 22 Canadians dead and 35 others gravely ill (many with permanent disabilities) in the summer of 2008.
Ms. Weatherill also demonstrated that a bloated, time-consuming public inquiry was not needed. Her six-month, $2.7-million effort was more than sufficient.
Stated briefly, improperly cleaned and inadequately inspected equipment at the Maple Leaf Foods plant on Bartor Road in Toronto led to the contamination of luncheon meats with listeria monocytogenes.
Yet, the root of the problem was not two dirty meat slicers but rather a culture - in government and private enterprise alike - in which food safety was not a priority but an afterthought.
Maple Leaf Foods found significant quantities of listeria in its meats as far back as 2007, but had no obligation to report this to the Canadian Food Inspection Agency. The CFIA inspections were lackadaisical. And when it became obvious there was an outbreak of food poisoning, the response from CFIA and the Public Health Agency of Canada was clumsy and slow, and fraught with petty disputes about jurisdiction.
Communication with the public about the extent of the outbreak and who was most at risk (frail residents of nursing homes and long-term care facilities) was appallingly bad. The deaths started in June but the public wasn't truly warned until August.
"The investigation has made clear that much more could have been done to prevent this from happening in the first place," Ms. Weatherill said diplomatically at her press conference this week.
More important, she added: "Much more must be done to make sure it does not happen again."
Let's not forget that there are an estimated 10 million cases of food poisoning in Canada annually and at least 500 deaths. Listeriosis in luncheon meats is but a small part of the problem.
The independent investigator made 57 recommendations for improving food safety, every one of them eminently sensible and easily do-able.
They include technical fixes such as designing meat-processing equipment that is easier to clean, administrative changes including requiring companies to report internal test results to government inspectors and more frequent and thorough plant inspections, organizational changes such as giving the PHAC a larger role when there is an outbreak of food-borne illness, and the need for better consumer education.
But Ms. Weatherill's most important recommendation - one that has been largely glossed over in media coverage of the report - is for a culture of safety or, as is stated bluntly in the report: "Actions, not words."
She said that "in setting its agenda for the fall of 2009 … the government should clearly and emphatically commit to the safety of food as one of its top priorities."
Ms. Weatherill added: "Everyone involved in the events leading to, and in managing the response to, the 2008 listeriosis outbreak should view the lessons learned from this tragic event and the recommendations as imposing an obligation to pursue innovation and improvement."
Ms. Weatherill knows of what she speaks. In her long career, from bedside nurse to chief executive officer of Capital Health in Edmonton, she has always been an innovator - a doer and a decision maker.
In her report, Ms. Weatherill pointed repeatedly to the "void in leadership" within the federal government. She was referring specifically to the lack of co-ordination among various governmental and quasi-governmental agencies including the CFIA, the PHAC, Health Canada and Agriculture and Agri-Food Canada.
But she could well have pointed up the political food chain. Let's not forget that Prime Minister Stephen Harper called this inquiry as the last order of business before an election, no doubt as a means of avoiding serious discussion of the issue. Then-Minister of Health Tony Clement and Minister of Agriculture and Agri-Food Gerry Ritz both heaped praise on their officials, yet this report makes clear that there were massive, patently obvious failings.
Is it too much to expect the public service to serve the public, for ministers to minister, for governments to govern?
No. These too are obligations.
The real lesson from listeriosis is not to be found strictly within the report of the independent investigator but rather in the larger principles that guided Ms. Weatherill's recommendations: You need to invest in public-health infrastructure, particularly in good people; you need to value prevention, not just pay lip service; voluntary measures need to be complemented with strong sanctions for failure; and when threats to public health occur, you need to act forcefully and communicate well.
Above all, you need to take responsibility - in business and government alike, and in everything from policy to everyday actions.
There is a leadership void, one that is a much bigger threat to the health of Canadians than a bacterium such as listeria.
How the government responds to this report will be a test of leadership, so the Prime Minister's Office needs to underline three words: "Actions, not words."