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The Canadian Food Inspection Agency in Ottawa on June 26, 2019.Sean Kilpatrick/The Canadian Press

The revelation, when it happened, was surprising. And disturbing.

At the outset of The Globe and Mail’s four-month investigation into this summer’s listeria outbreak involving plant-based milks sold under the Silk and Great Value brands – which killed three people and left others seriously harmed – public-health officials said they had traced its origin to a production facility in Pickering, Ont.

The facility made a variety of almond, oat, cashew and coconut milks, and a massive recall ensued. However, when federal officials conducted genome sequencing on the culprit bacteria, they found the same genetically-related strain had caused illnesses as far back as August, 2023. According to food-safety experts, that meant for 11 months, a listeria problem existed inside the facility.

This raised an unsettling question. How could the problem go that long without being detected? Reading through documents that lay out Canada’s food-safety oversight system, two things are clear: companies are supposed to be keeping a watchful eye in their plants for listeria, and the Canadian Food Inspection Agency is supposed to be keeping a watchful eye on them.

However, sources inside the government warned of a bigger problem: a breakdown of that federal oversight system had occurred.

In the course of this investigation, The Globe reviewed more than 400 pages of government regulations and food-safety documents detailing how such facilities should operate, examined eight industry lawsuits and spoke to several current and former officials inside the CFIA and the federal public-health agency, along with food-safety experts from around the world.

The information from each of those sources formed a puzzle, which eventually led to one critical revelation that the government acknowledged in October in response to questions from The Globe: the plant hadn’t been inspected for listeria during the 11-month outbreak period.

When pressed on the matter, the CFIA then told The Globe a few weeks later that the last time an inspector visited the plant was five years ago, but that visit wasn’t related to listeria inspections. Then asked when the last time the plant was specifically inspected for its listeria protocols, the CFIA couldn’t say.

As the head of the union representing CFIA inspectors also told The Globe: “We never checked that plant. The algorithm didn’t require us to go in.”

The algorithm? Never did we think the trail of reporting would lead there. But in a revamp of food-safety oversight in Canada, the CFIA had moved to an algorithm-based system where risk calculations determined which plants in Canada are inspected and – conversely – which facilities get less attention, or none at all. It was a recipe for a problem, two inspectors inside the CFIA told The Globe.

At its heart, this is a story about lapses in oversight that affect all Canadians. It’s also about the victims: the son whose 76-year-old mother died of listeriosis; the mother who believes her miscarriage was a result of the oat milk she drank; the woman who feared for her seven-year-old daughter’s life.

But figuring out how that happened was a web that took months to untangle. Though sources behind the scenes were helpful in providing crucial information, the CFIA would not agree to an interview, only e-mailed responses. Same-day answers weren’t possible. And if the replies were unclear, or lacked detail, the need for further questions led to more delays. With the department declining all in-person or telephone interviews on this subject, The Globe posed more than 90 questions to the CFIA over the span of two months.

Ultimately, this story is about more than a single product recall. It’s about gaps in a system that Canadians rely on to keep them safe. And it’s about what Cale Sampson, whose mother died this summer in Toronto, wants for her legacy: answers. Not just for himself, but for others across the country.

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