A damning report on a deadly source of food poisoning last summer that claimed 22 lives across Canada says the country's top medical officer of health was missing in action, forcing Maple Leaf Foods chief executive officer Michael McCain to jump into the void and become the public face of the crisis.

In a report released on Friday into the listeriosis outbreak linked to Maple Leaf meats, Ontario's Chief Medical Officer of Health blames a lack of co-ordination among various levels of government for contributing to confusion among the public and shaking their confidence in the health system.

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.

However, Dr. David Williams refused to say during a news conference whether the lack of timely information to the public about the severity of the outbreak contributed to the number of fatalities.

Because such an outbreak can happen again, the report recommends that Canada adopt better systems to investigate and manage food borne illnesses. The federal Chief Public Health Officer should take the lead in managing an outbreak and be the public spokesperson, the report says.

“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.

The current systems for investigating and managing outbreaks are not adequate to support a co-ordinated response among different levels of government, the report says. Canada also needs to improve the capacity of laboratories to conduct a wider range of tests and monitor strains of bacteria that pose a threat to public health, it adds.

The report also singles out the Canadian Food Inspection Agency for criticism, saying it refused to tell officials in the Ontario Health Ministry where the Maple Leaf meats contaminated with the listeria bacteria had been distributed.

As a result, the report says, health officials in Ontario did not learn until August 14 - one month after two cases in a Toronto nursing home were linked to Maple Leaf meats - that the contaminated meats might also have been distributed to grocery stores and deli counters.

“If public health authorities had had timely access to this information, they might have been able to take additional targeted steps to reduce possible exposure among the general public,” the report says. “The lack of information about the national distribution of affected products also hampered the national investigation of the outbreak.”

The CFIA never did issue a mandatory recall of deli meats made by Maple Leaf, the report says. The company issued its own voluntary recall that began with two products and eventually expanded to over 220 made in the same plant.

“The ever-expanding list of products and stores affected created the impression that the response was not well organized, and contributed to the public's sense of unease and confusion,” the report says.

A spokesman for the CFIA responded to the provincial report Friday, saying the agency will look at all of the recommendations with a view to “continual” improvement.

“This includes reviewing the recommendations of the federal investigator, the subcommittee of the Standing Committee on Agriculture and Food, our own internal reviews, as well as the province of Ontario,” Tim O'Connor said in an email to The Globe.

Agriculture Minister Gerry Ritz was the chief federal spokesman during the listeriosis crisis – the CFIA comes under his ministry.

Dr. Carolyn Bennett, Federal Liberal Health Critic, blames the Harper government for allowing politics to interfere with the handling of the crisis.

“It would appear that their lack of communications with the Ontario Ministry of Health stemmed from their desire to limit political damage, rather than putting the lives of Canadians first,” she said on Friday.