We love Canada and the UK. After every major outbreak, there is always some high level inquiry or royal commission to hear from. This time, its Dr. David Williams, Ontario’s Chief Medical Officer of Health, making the report on the listeria outbreak blamed on the meat cutting machinery at Maple Leaf Foods Toronto plant.

Dr. Williams paints Canada’s top medical officer as being such a weak link in the chain that Maple Leaf Chief Executive Officer (CEO) Michael McCain had to pick up the slack in managing the  outbreak that eventually spanned Canada and killed 21 people.

Canada’s newspaper of record, The Globe & Mail, summed it up this way:

The report, released just before public hearings begin on Monday in Ottawa into food safety, singles out the Public Health Agency of Canada for not playing a leadership role in an outbreak that spread to seven provinces, leaving 56 mostly-elderly individuals sick and 21 dead. Ontario was hardest hit, with 16 of the deaths, and most of the victims were in long-term care homes or in hospitals before becoming ill.

The report predicts more outbreaks in the future. “Cross-jurisdictional outbreaks, such as the listeriosis outbreak lat year, are likely to become more common because of the trend to large-scale food manufacturing and processing,” Dr. Williams said.

For more on the report and the hearings coming up on Monday in Canada, go here.