Had the listeria problem been caught at the Pickering facility, and the bacteria contained, Cale Sampson believes his 76-year-old mother, Muriel, would still be alive. Mr. Sampson poses while holding a framed photograph of his mother in the empty apartment where she lived prior to her death from listeria, in Toronto, on Nov. 3.Christopher Katsarov/The Globe and Mail
Federal Health Minister Mark Holland has called on the Canadian Food Inspection Agency to review the algorithm-based system used by the agency that determines how often – or how little – food producers are inspected, amid concerns that facilities in Canada are not being properly scrutinized.
A Globe and Mail investigation this month found the CFIA’s move to an algorithm-based system for prioritizing inspections misjudged the risk associated with a facility in Pickering, Ont., that was linked by public-health officials to a deadly listeria outbreak this summer.
The agency deemed the facility was not a high priority for inspections. As a result, the site had not been visited by a CFIA inspector for five years before the listeria outbreak killed three people, The Globe found. Under the algorithm system, the job of scrutinizing the operation – including checking safety procedures and swabbing for listeria – was never flagged for an inspector, the investigation found.
“The minister is extremely concerned and aware there were gaps,” Mr. Holland’s spokesperson Alexandra Maheux told The Globe.
The review will examine gaps in how the algorithm, known as the “Establishment-based Risk Assessment model,” or ERA, was designed, and how it should be improved or overhauled, Ms. Maheux said.
“What we’ve directed CFIA to do is look into how they can improve risk analysis of what facilities get inspected and how often, and how this gets decided,” she said.
“It includes directing them to look at the ERA [algorithm] and what feeds into that tool.”
They are the first comments from Mr. Holland’s office on The Globe’s investigation.
Among The Globe’s findings were that the majority of the data fed into the CFIA algorithm to conduct risk calculations on the 8,000 federally licensed food-production facilities in Canada are provided by companies themselves, and often not verified by the agency. Such gaps in oversight meant the facility in Pickering was effectively left to police itself in the years leading up to the crisis.
Public-health officials linked the listeria outbreak to plant-based milks produced at the facility and sold under the Silk and Great Value brands, which were recalled on July 8. The outbreak sickened 20 people, including three deaths, and is one of the most serious and prolonged on record involving Canadian-made products.
When public-health officials examined the outbreak in early July, they determined through genome sequencing that a similar strain of listeria had turned up in two illnesses reported in August and September of 2023.
That meant a listeria problem existed inside the facility for 11 months without being detected, food-safety experts say.
Had the problem been caught, and the bacteria contained, Cale Sampson believes his 76-year-old mother, Muriel, would still be alive. The Toronto grandmother died in June of listeriosis, about a week after consuming Silk unsweetened coconut milk that was later recalled.
“There was a breakdown at the root level in a system that Canadians put their faith and trust in, and it cost her her life. And it caused suffering on her and other people,” Mr. Sampson said in a recent interview.
The Globe spoke with others who said they were affected by the products, including a 32-year-old woman who miscarried last December – both she and the fetus tested positive for listeriosis – and a 28-year-old man who was nearly paralyzed with bacterial meningitis, which can be caused by listeriosis.
The algorithm system was introduced a few years ago as a way to prioritize CFIA inspections toward the highest-risk facilities, such as meat processors. In doing so, however, the algorithm deemed many other sites lower-risk, making them far less likely to be inspected, if at all.
The algorithm-based approach is now under heavy criticism from food-safety experts and victims amid the lapses in oversight that have been exposed.
Despite the dangers associated with such outbreaks, the last time the CFIA visited the Pickering facility, in 2019, it was for a matter unrelated to listeria, and the site did not undergo a formal inspection. Asked by The Globe when the last time an inspector had been inside the Pickering facility to examine its listeria safety protocols, swab for signs of the bacteria, or to question the company on its procedures, the CFIA said it could not say.
Prior to Ms. Maheux’s statements, neither the agency nor the minister’s office had previously acknowledged potential problems with the algorithm-based system in responses to The Globe’s questions.
Key inputs fed into the algorithm that help determine a facility’s risk level, such as how often the food manufacturer monitors for outbreaks by swabbing its machinery for listeria, are not mandatory under current CFIA regulations.
Last week, The Globe investigation reported that CFIA data show almost one-fifth of the country’s federally licensed food-production facilities have not been properly assessed for risk under the algorithm system, because those companies have yet to submit the necessary information to the agency. As a result, 1,443 operations have instead been given a default rating by the agency that deems them among the lowest priorities in the country for inspections, even though they have yet to be independently examined.
All of the unassessed facilities produce what are known as manufactured foods. This category, which comprises food made at roughly half of the country’s federally licensed facilities, includes products such as condiments, oils, baby foods and vegan dairy substitutes. It does not include meat producers and dairy processors.
The issue of company-supplied data points, and whether they have too much influence over how the algorithm prioritizes sites for inspections, is also now being reviewed.
Mr. Holland has directed the CFIA to examine whether “measures that industry feed in themselves have to be made mandatory, do they need to bear different weight in the algorithm, and how do the managers use this tool as part of their overall decision and planning?” Ms. Maheux said.
In mid-November, about a month after The Globe began asking the CFIA detailed questions about whether the Pickering plant had been inspected prior to the listeria outbreak, and later about the role the algorithm would have played in the lack of scrutiny, the CFIA set out to do an internal audit of the system on its own.
However, the CFIA never chose to disclose this process in responses to more than 90 questions sent by The Globe over a two-month span.
According to federal procurement records, the CFIA put out a call on Nov. 15 for a performance analysis that would give the agency comfort about how the algorithm works. Candidates had two weeks to apply.
“The preliminary objective is to provide assurance that the CFIA’s Establishment-based Risk Assessment (ERA) Food Model is allocating and prioritizing CFIA inspection resources according to food safety risk,” the procurement records say.
The CFIA said Friday in an e-mail that it regularly conducts internal audits. Asked if its own process is taking an objective look at the algorithm, given that the agency is seeking “assurance” about the system it built, the CFIA did not respond.
In a statement to The Globe last week, Pamela MacDonald, CFIA executive director of inspection support, said the agency is also considering “how we analyze consumer complaints trends to inform inspection planning.”
The Globe investigation highlighted how the Pickering facility was the subject of consumer complaints about alleged mould, which led to the 2019 visit by the CFIA and another in 2018, which food-safety experts say should have flagged it as a higher priority for inspections.
Mr. Holland, in October, called the listeria outbreak a tragedy.
“Any time as a result of problems in the food supply there’s death, it’s entirely unacceptable. And so, it’s imperative that we shut any deficiencies and understand what went wrong,” he said at the time.
The CFIA’s Inspector General is expected to complete its findings on the outbreak in April. Ms. Maheux said the agency will then take those conclusions into account, along with the current questions being raised about the algorithm, and determine what policy fixes will be made.
“It’s incredibly important that CFIA does this detailed analysis and report we’ve directed them to do,” Ms. Maheux said. “Once this is complete, we will be able to answer next steps.”