OTTAWA - An investigator's 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.

Sheila Weatherill's sweeping probe, released Tuesday, found a confluence of events led to one of Canada's worst food-borne illness outbreaks.

"There are simply no easy answers," Weatherill said. "Last summer's outbreak was rare and it was a complex event that defies simple explanations and simple solutions."

The report found governments and industry didn't focus enough on food safety before the outbreak began.

No one told top executives at Maple Leaf Foods that a plant in Toronto started to see more cases of Listeria in March 2007 -- more than a year before the outbreak -- because it was thought cleaning the equipment had fixed the problem.

Since the company wasn't then required to report positive tests for the Listeria or analyze trends to spot problems, no one knew about deadly bacteria lurking in the machinery.

The probe found 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 and didn't take it seriously enough after it started last July, leading to a "a void in leadership in managing the crisis," the report says.

The report also found 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."

It took nearly three weeks before top officials from all the government bodies started to work together. Even then, the document says, their efforts were muddled in confusion.

"The lack of a clear understanding about which organization or level of government was responsible for doing what -- including which organization should lead the response to the crisis -- contributed to the inconsistent management of the outbreak."

The report says 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 document does not include findings of criminal or civil liability. It does make 57 recommendations to help prevent another outbreak.

Meat companies should 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.

And it says Canada's chief public health officer should be given the lead role during outbreaks of food-borne illnesses.

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 he welcomed the Weatherill report's findings.

"That focus of effort is clearly a good blueprint for the future for both government and industry," he said.

The company favours the Canadian Food Inspection Agency getting more resources, as well as more government regulations around food safety, McCain added.

Agriculture Minister Gerry Ritz said government's responsibility to those affected by the deadly bacterial outbreak is to create a better food-safety system.

"At the time of these tragic events, the different levels of government and departments involved simply did not co-operate effectively enough," he said.

"Many of these issues have been identified by other reports, and we are already taking action to strengthen our food-safety system."

Bob Kingston, head of the agriculture union representing federal food inspectors, said the Weatherill report fell short by not being able to determine how many federal meat inspectors are working in plants.

"It is literally beyond my comprehension," he said.

Weatherill has suggested an outside auditor do a count.

New Democrat MP Malcolm Allen, the party's food safety critic, criticized the investigation for being carried out behind closed doors.

"From the get-go, it was a non-public inquiry," Allen said.

He added many of the recommendations in Weatherill's report were already made in a separate report tabled last month by a special panel of MPs studying food safety.