The listeriosis outbreak that killed 22 people last year was not taken seriously enough in its early days, concludes a report that offers 57 recommendations for preventing future outbreaks.

"What we found is that last summer, our food safety system did not work as perfectly as it needed to," investigator Sheila Weatherill told a news conference Tuesday morning.

"The investigation has made clear that much more could have been done to prevent this from happening in the first place and more to that point, much more must be done to make sure it doesn't happen again."

Weatherill's report found the Maple Leaf Foods plant that was the source of the outbreak failed to notice its problem with Listeria contamination on its meat-slicing machines. Over-extended government meat inspectors also failed to identify the problem.

Once reports of illnesses began to mount, the outbreak was not considered a severe food-borne emergency, as it should have been.

"This led to a void in leadership in managing the crisis," the report alleges. "It took close to three weeks before senior executives in all key organizations became fully engaged in the event."

There were also failures in communicating the crisis to the public and to those in institutional food services, which received most of the contaminated meat product.

"Federal communications to the public were slow off the mark, and were not sustained for a sufficient period of time. In addition, there was no designated communications coordinator, which resulted in a fragmented approach and seemingly inconsistent messaging," the report notes.

While Maple Leaf Foods president Michael McCain welcomed the findings as rigorous and comprehensive, he said that there are "no guarantees" that a similar outbreak won't happen again.

"Our job is to produce safe food ... that never means the hardened word of guarantee," he said Tuesday.

Still, McCain said that the systems for food safety are a huge improvement over the ones in place last year.

"Had (they) been in place then, we believe we would have saved 22 lives," he told a news conference.

"We have learned our lesson."

Key findings

As CTV News reported Monday, Weatherill's report calls for a number of changes including:

• More unannounced federal spot checks at meat facilities. Currently, meat plants are given 72 hours to 30 days notice ahead of inspections.
• Ensuring that food companies alert public officials as soon as they suspect a health threat, rather than wait until they have a positive lab tests.
• Having Canada's chief public health officer take the lead role in a food-borne illness crisis, not government officials.
• Requiring meat processing equipment manufacturers to design equipment that is easy to clean.

The report is the result of a six-month probe headed by Weatherill, a former Edmonton health care executive, who conducted more than 100 interviews and amassed some five million pages of information.

Agriculture Minister Gerry Ritz told reporters Tuesday he accepts Weatherill's report and noted that some of her recommendations have already been implemented, while others can be implemented quickly.

"We now have a critical mass of research and recommendations," Ritz told a Parliament Hill news conference.

"...All of these reviews have clearly identified opportunities for improvement. This is a turning point. The reports are in. We will continue to resources, regulations and legislation where required to strengthen our food safety system."

However, Ritz said that Ottawa won't compensate the victims' families.

Liberal MP Carolyn Bennett said Weatherill's report was "a good blueprint for going forward."

But the Liberal party health critic also said the report did not go far enough in uncovering the reasons why Canada's chief public health officer did not take the lead role during the listeriosis outbreak -- a responsibility that is already part of his job description.

"We are very upset that the mandate of her inquiry couldn't go far enough to find out what on Earth happened that the chief public health officer for Canada was not front and centre in the outbreak last year," Bennett told CTV News Channel during an interview on Tuesday evening.

Maple Leaf Foods apologized shortly after last summer's outbreak and agreed to pay up to $27 million to settle class-action lawsuits. The company has since instituted more rigorous testing for Listeria in plants producing ready-to-eat meat.