Officials at Toronto Public Health and the hospital where the first SARS case appeared went back and forth for at least three days before deciding whether to call 210 at-risk patients, a Toronto Star investigation has revealed.

The 210 patients had been at Scarborough Grace Hospital on March 7, the night the first SARS patient came in.

Documents obtained by The Star show that a memo sent by Toronto Hospital Health Staffer, Carolyn Ostach, describe the hospitals decision on March 16 not to call the patients.

"Linda Davis (a Grace infectious disease expert) informed me that they had sent their extra staff home and that they -- the hospital -- would no longer be calling the outpatients," one of the documents states.

Toronto Public Health's Gene Long believes the calls began to get underway on March 18.

The Star's investigation revealed that at least one of the 210 was never called and two deaths and at least 15 new infections resulted.

Toronto's chief medical officer of health, Sheela Basrur, told The Canadian Press that it was difficult to keep track of the hundreds of exposed patients and thousands in quarantine.

"Someone takes the file. 'Where is the file? OK, well you look that way and I will look this way.' It's the dumbest thing in the world. I can't believe this is the state of affairs," Basrur said.

The Star investigation also found that the first group of patients with SARS, five members of one family, were dismissed at first as having tuberculosis. It wasn't declared SARS until seven days after the first patient was brought in.

The report is based on interviews with more than 100 people involved in the outbreak, including the relatives of the those who died of SARS, nurses and doctors. Documents were also obtained by the Star under the municipal freedom of information act.

In total, SARS killed 44 people in Canada and infected at least 375 people.

In comments made last week, Dr. David Naylor, the head of the inquiry into Canada's handling of the SARS crisis, slammed almost every aspect of the public health system, calling the country's response a "national embarrassment."

He said alerts about SARS were slow to reach Ontario doctors, hospital infection control measures failed, directions were unclear and a national surveillance system didn't exist.