An algorithm was supposed to fix Canada’s food safety system. Instead, it missed a deadly listeria outbreak | Canada Voices

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One of the last memories Cale Sampson has of his mother is from a Friday afternoon in June. He was walking his son home from school and when they rounded the corner, Muriel looked up from her yard work and greeted them with a beaming smile.

“It was beautiful,” he recalls.

That night, they ate dinner on the patio of their Toronto home and his mother chatted with the neighbours. She was 76 and even though she had been diagnosed with colon cancer, she was doing everything she could to stay healthy.

She was eating better and staying active, doing chores around the house and running errands across town. She was full of energy, and seemed younger than she’d been in years.

Days later, though, Muriel Sampson was on life support, unable to breathe on her own. The sudden decline in her health was so rapid and unexpected that it confounded her doctors.

It began with a slight headache on Saturday, then a fever. By Monday, she was disoriented and vomiting. On Tuesday, she was in the ER, stricken with pain down her back. By Wednesday, she’d been moved to the intensive care unit, having lost the ability to breathe or swallow.

“I can’t believe it,” the doctor told Mr. Sampson when the blood cultures came back. It was listeria.

Her case of listeriosis, the foodborne illness caused by the listeria bacteria, was one of the worst he’d seen, Mr. Sampson recalls the doctor saying. Muriel was a fighter, but the infection was too advanced, and too aggressive.

“That’s when the energy just shifted, and everybody lost hope,” Mr. Sampson said.

One week after the first symptom hit, she was gone. Mr. Sampson was overcome with grief. Reeling from the shock, he ordered a copy of her death certificate. “Anything that will help prove this is all real,” he said.

Public-health records now list Muriel, who died on June 22, as one of three casualties this year in one of the country’s most serious and prolonged listeria outbreaks on record involving Canadian products.

After multiple patients began showing up in hospital, the problem was linked by federal public-health authorities to a brand of plant-based milk, sold under the name Silk. That prompted a recall on July 8 of almond milk, coconut milk and other varieties produced on the same production line, under the Silk and Great Value brands.

As part of her quest to be healthier, Muriel had switched to Silk unsweetened coconut milk.

The Public Health Agency of Canada says 20 people were sickened, three of whom died, by the same genetically related strain of listeria. However, interviews by The Globe and Mail show the true numbers are likely higher, since not all of those who became ill were counted. The official numbers also do not include miscarried pregnancies.

The outbreak has left a trail of damage, from hospitalizations to life-altering health issues. The Globe interviewed a healthy 27-year-old man who says he consumed Silk almond milk and later awoke in the intensive care unit partially paralyzed by severe meningitis, which can be caused by listeriosis, and a 32-year-old woman who connects her second-trimester miscarriage to Silk oat milk.

But the factors behind this outbreak go beyond the oversight of any one brand or product. What unfolded this summer has exposed broader implications for many of the items Canadians keep in their refrigerators and pantries.

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Public-health officials linked the listeria to a manufacturing facility in Pickering, Ont. But when they examined the genome sequence of the bacteria – a forensic technique for investigating food-borne illnesses – they discovered a much bigger problem.

A genetically related strain of listeria involved in this summer’s recall had, in fact, been detected in two cases of listeriosis reported almost a year earlier, as far back as August, 2023.

That means, experts say, that for 11 months, a listeria problem existed inside the manufacturing facility.

The Globe reviewed more than 400 pages of government regulations and food safety documents detailing how such facilities are intended to operate, and spoke to six current and former government officials, including sources inside the Canadian Food Inspection Agency (CFIA) and the federal public-health agency – as well as food-safety experts from around the world.

A key aspect of the food-safety system is that companies are supposed to regularly swab their facilities for evidence of listeria, including on the machinery used to make and package food and beverages, and quickly report any problems to the CFIA.

But it wasn’t until more than three months after the recall was announced, when The Globe sent a list of questions to the CFIA about their inspection practices, that the agency acknowledged publicly this October that a failure in the system had occurred.

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The facility was operated by Joriki Inc., a privately owned company that was contracted by French dairy giant Danone SA to make the plant-based milk products. Joriki did not follow federal policy for swabbing the facility for listeria, the CFIA said in October. And this week, the agency told The Globe that the company had not been conducting any testing for the bacteria in finished products or on any food contact surfaces.

Joriki disputes those allegations.

In a statement to The Globe, Joriki said it had a monitoring program for listeria in place, which included swabbing the production line and conducting finished product testing, and that its program “exceeds CFIA requirements.” But the company did not share what those tests found.

The CFIA never raised any concerns about its program prior to the outbreak, the company said, adding that it has only seen government data on one of the cases.

But The Globe’s investigation found there were oversight problems that reached up to the federal level. Before this summer’s deadly outbreak, no CFIA inspector had visited the site to ensure federal food-safety policies were being followed under the terms of its licence, to test for listeria, or to conduct an on-site verification of the company’s paperwork or procedures. In fact, the CFIA says the last time it sent an inspector to the building was in 2019, for an unrelated matter that involved no checking on listeria protocols.

Had the contamination been found, and the bacteria contained earlier, lives may not have been lost.

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This lapse was due to a flaw in the system, The Globe investigation found. According to two current inspectors, and one former inspector, in recent years the CFIA has increasingly let many food manufacturers in Canada police themselves under a new method of oversight brought in with the goal of making the system work more efficiently.

In a pivotal shift, the department placed its faith in a risk-based approach that decided which facilities in Canada would be inspected closely, and which would not be scrutinized as often – or at all.

Based on data mostly supplied by the companies, this system determines where inspectors spend their time – and which facilities they don’t visit.

And for several years before Muriel Sampson and others died or were hospitalized, the system never flagged Joriki’s Pickering facility for inspection.

Milton Dyck, national president of the Agriculture Union, which represents CFIA inspectors, told The Globe there was a gap in oversight.

“We never checked that plant,” he said. “The algorithm didn’t require us to go in.”

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A bold promise

Canada’s worst listeria crisis occurred in 2008, when at least 57 people were hospitalized and 24 people died as a result of an outbreak inside a Maple Leaf Foods plant in Toronto that produced sliced lunch meat.

Listeria can harm anyone, but it is particularly dangerous for the elderly, children and those who are pregnant or have immune deficiencies. In the Maple Leaf Foods crisis, a portion of the lunch meat was distributed to long-term care homes, which made it especially deadly.

An independent federal probe into that outbreak, the results of which were made public in 2009, determined that staff at the production facility had detected listeria through routine swabbing of the machinery, but attempted to correct it themselves, without escalating the matter.

“Employees were not required to disclose information on repeated listeria occurrences to CFIA inspectors,” wrote Sheila Weatherill, a former president of the Edmonton health authority who led the federal investigation. It was one of many gaps she said needed to be rectified, to ensure such a tragedy would never happen again.

But the report pointed out another significant problem: “In the lead-up to the outbreak, the number, capacity and training of inspectors assigned to the Maple Leaf plant appear to have been stressed due to responsibilities at other plants.”

In a growing food-processing sector in Canada, CFIA inspectors were stretched thin. The country’s roughly 3,000 inspectors have a range of responsibilities beyond examining food-production facilities, including looking for disease in potato crops, avian flu in chickens and bovine spongiform encephalopathy in cattle – as well as inspecting certain foods destined for export.

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The Weatherill Report made 57 recommendations to avert another deadly crisis. Among them, the CFIA should “accurately determine the demand on its inspection resources and the number of required inspectors.”

The department had two years to respond. And when it did, in 2011, a new system was touted. However, instead of focusing on adding resources – inspector numbers have remained relatively stable since that time – the CFIA planned to change how the oversight process worked, including the amount of swabbing for harmful bacteria in food manufacturing facilities, known as environmental sampling.

“The frequency of required environmental sampling is being adjusted,” the CFIA said in its response to the Weatherill Report.

In short, the agency would increasingly divert inspection resources toward products or facilities deemed to be a higher risk, and spend less time on others.

Meat-production facilities, like the one at the heart of the Maple Leaf crisis, would get the bulk of attention. Foods made for export would also be a primary focus, because of U.S. demands for regular inspections of those plants, and the worry that any problems could spark an international trade dispute.

Other plants would get less attention.

“CFIA will continue to identify establishments producing lower-risk products and decrease the level of sampling required for these establishments,” the agency said.

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Over the next few years, the CFIA created what it called the “Establishment-based Risk Assessment Model,” or ERA for short, which was outlined in the hundreds of pages of agency documents reviewed by The Globe, including departmental plans, notices of procurement and guidance to industry.

The shift came with a bold promise.

“In a world of changing risks, innovation and new technologies, the CFIA is adapting to be more efficient and responsive,” the agency said in a document titled “Building for the Future,” which details the ERA model.

“The model uses data and a mathematical algorithm to determine the level of risk to inform oversight required by inspectors.”

Most importantly, it would guide how often inspections occur at Canada’s roughly 8,000 federally licensed facilities. The ERA helped determine “where CFIA inspectors should spend more or less time.”

The algorithm incorporates 16 key risk factors, including the type of product being made, how it is produced and what mitigation steps are present to prevent food-borne pathogens, including swabbing, pro-active sanitation schedules and whether pasteurization steps are used. A facility’s record of compliance, including past infractions, recalls or customer complaints, are also factored in.

But as they sought to revamp the system, the pendulum swung too far. Resources directed toward plants deemed top priorities left others exposed, say the three inspectors who spoke with The Globe. And if facilities were cutting corners, there was less on-the-ground scrutiny to crack down.

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Bob Kingston, a former inspection supervisor who spent 38 years at the CFIA before retiring in 2017, said he had issues with the concept when it was in its infancy.

Under the old system, an inspector could use discretion on which plants needed more attention if, for example, a facility was deemed to be a compliance problem. Also, if a site hadn’t been scrutinized for a while, the inspector would factor that into their workload, rather than let a facility go long periods of time with no scrutiny at all.

“The problem with the current system where everything is totally algorithm-based is it doesn’t allow for inspector judgment,” Mr. Kingston said. “I did raise some red flags for them at the time.”

He mostly worried the algorithm could lead to a situation where plants that should be inspected were being missed.

After a trial period, the algorithm software was implemented in 2019, starting with the dairy and maple syrup sectors. By 2023, it was in place across the food-safety system in Canada.

The Globe spoke with two current CFIA inspectors who detailed how the algorithm governs their work, deciding which sites get the bulk of the attention and which do not. The Globe isn’t naming the two inspectors because they fear reprisals for speaking publicly.

When an inspector starts their week, tasks are ranked in descending order from Priority 1, the highest priority, down to Priority 7, the lowest. Meat-processing plants and any foods destined for export are at the top, while other facilities appear lower on the to-do list, or not at all, based on the 16 factors plugged into the algorithm. But how the risk calculation actually spits out the priority ranking is a mystery to the inspectors.

The Globe’s investigation found Joriki’s Pickering facility at the heart of this summer’s recall was ranked Priority 3, which should have put it in line for an in-person inspection at least once a year, and more if there were problems, according to the CFIA.

But the inspectors said even Priority 3 would be too far down the job list for an inspection to actually happen.

Given the workload involved at Priority 1 and 2 sites, those facilities alone can be more than CFIA staff get to in a week or a month, one inspector said.

Nor is the Pickering facility an outlier. A second inspector said there are many plants across Canada that should be inspected more regularly, but are not.

The lack of oversight on the Pickering plant is an issue the CFIA didn’t talk about publicly in the months after the recall was announced in July. But when The Globe asked in October if officials had inspected the facility for listeria at any time from June, 2023, to late June, 2024, when the link to Silk products was discovered, the agency confirmed no such scrutiny had taken place.

The Globe investigation found even the task of examining the facility had not been assigned to an inspector in recent years. Asked when the last time an inspection for listeria was done inside the Pickering plant, the CFIA could not say.

“Prior to June 26, 2024, the CFIA had not conducted any routine licence inspections, environmental swabbing, or evaluated the company’s procedures for controls for listeria monocytogenes at the Pickering facility, as the establishment was not considered a high priority due to its level of risk,” Meghan Griffin, the CFIA’s acting manager in the Office of Food Safety and Recall, said in an e-mailed response to The Globe.

It was only after public-health officials in Ontario alerted the department in late June to a potential problem with Silk products, based on patients showing up in hospital emergency rooms, that an inspector entered the building.

At that point, once inspectors were inside the facility, the agency said it discovered the plant wasn’t following federal procedures for how often, and where in the plant, it should have been swabbing.

“The facility did not properly implement environmental swabbing and finished product testing in adherence with Health Canada’s policy,” Ms. Griffin said.

Joriki maintains it complied with all federal laws. “It is not accurate that we did not have a finished goods testing program in place,” the company said in its statement to The Globe. “We conduct extensive tests on every batch prior to release, which would identify the presence of any microorganisms, including listeria.”

The company would not provide the findings of its own swabbing to The Globe, but said its listeria monitoring program “was available for review and inspection by the CFIA at any time.”

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So how often should it have been testing? There are no set rules. That was up to the company, which makes it difficult to enforce.

“It is the responsibility of the manufacturer to determine the frequency of environmental testing,” Ms. Griffin said, adding that the CFIA provides “guidance to industry” on testing frequencies.

She said these frequencies “are not mandatory,” but they must have documentation showing that their listeria-control program is adequate.

Publicly, the CFIA gives an impression such oversight takes place. Under the risk-based system, the federal government’s policy on listeria states: “It is the role of the CFIA to verify compliance with federal food legislation.”

But in the case of Joriki’s Pickering plant, the CFIA never checked for compliance. For the 11-month outbreak period, and long before that, the agency never followed up to verify what the facility was doing. No inspectors were at the plant to check if these listeria-control practices were being undertaken properly, or to swab for listeria themselves.

“Basically, it’s a self-regulation process. That means it’s on nobody’s job list,” said former inspection supervisor Mr. Kingston.

“It wouldn’t surprise me that something went that long without being seen, because no one’s checking.”

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‘This isn’t possible’

When Sanniah Jabeen, a 32-year-old PhD student at the University of Toronto, became violently ill in December, 2023, Silk plant-based milks hadn’t yet been connected to the outbreak.

Ms. Jabeen was 18 weeks pregnant. She’d been nauseous during her first trimester but said she forced down smoothies made with Silk oat milk, determined to make sure the baby was getting enough nutrients. It was her first pregnancy – a boy.

When she began suffering intense headaches and vomiting, she initially dismissed them as pregnancy symptoms, until her midwife and her husband, Hassan Asif, both insisted she go to the hospital. She was shivering, feverish, foggy-headed. “I didn’t feel human,” Ms. Jabeen said.

An ultrasound indicated the baby was fine, and she was sent home after an IV fluid treatment.

The next day she was stricken by intense stomach pains. “I thought, ‘Is this contractions?’ But I knew it was too early,” she said. “I had never heard of preterm labour or preterm birth before. I thought, ‘This isn’t possible.’ ”

Alone in her bathroom, Ms. Jabeen delivered the baby. In the grief and fear of the moment, she remembers how tiny yet fully formed his lifeless body was, and that his eyes were open.

When she screamed, her husband rushed in from another room and together they collapsed on the floor. They called 911 and were taken to the hospital. The baby, wrapped in a blue sheet, didn’t leave their side until they turned over his remains for an autopsy.

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Ms. Jabeen tested positive for listeriosis. The autopsy revealed listeria was also present in the placenta, the amniotic fluid and the fetus. They thought back to everything Ms. Jabeen had been eating, racking their brains for what could have been the source.

In July, more than seven months later, Ms. Jabeen’s phone lit up with messages from friends alerting her to the recall of Silk and Great Value milks. They knew she had been forcing down those smoothies.

She was contacted by public-health officials after she was diagnosed, but doesn’t know if she is included in the outbreak statistics.

Like most consumers, Ms. Jabeen had trusted the system to keep her safe. But there are signs the company and its facility in Pickering were not as low-risk as the CFIA had calculated.

Under the ERA system, the majority of the inputs fed into the algorithm to determine the risk level of a plant are based on what the company self-declares about their own operations.

Of the 16 risk factors, 12 of them – including type of food production and sanitization procedures – are supplied by the companies themselves, through an online questionnaire, according to government documents and communications with industry that were reviewed by The Globe.

“Filling out this information will ensure you receive an accurate risk level for your establishment and will help inform the frequency and/or the intensity of future inspections,” says a CFIA document intended for industry.

This information is then inputted into the algorithm. But one of the current inspectors said the self-reported data are not always audited by the agency.

Mr. Kingston said that would have affected the algorithm.

“When [manufacturers] describe what they do, how they do it, where the risks are, and how they’re mitigated, all those sorts of things, that has to be audited from time to time,” he said. “Otherwise you have zero assurance that any of that actually transpires.”

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If a company has production and sanitization procedures in place that look effective on paper, and it is not believed to be producing high-risk food products, it can easily be moved down the priority list, the inspectors say.

Evaluating that information is a key part of on-site inspections.

“We know in some cases [companies] have described training programs and even listed personnel. And then finally somebody gets out there and there’s no training program, the personnel they’re describing haven’t worked there in years,” Mr. Kingston said, speaking broadly about his experience on the job, and not about Joriki in particular.

One of the current inspectors told The Globe that after the CFIA entered the Joriki plant this summer, the agency found the company’s paperwork inaccurate. The CFIA later confirmed this, stating that some of the information provided by the company – known as the Additional Establishment Information questionnaire, or AEI – that is fed into the algorithm had not been updated.

In particular, the CFIA said the company didn’t provide accurate information about the volumes of product being produced, based on new categories it introduced on the questionnaire.

“Joriki did not update their AEI,” Ms. Griffin said in an e-mail. “Updates to the AEI provide more detailed information for the risk assessment process.”

Asked about their questionnaire being inaccurate, Joriki said, “We are not aware of this.”

But the CFIA hadn’t sought to verify the information before the crisis.

Though the CFIA acknowledged in response to The Globe’s questions that no inspections took place at the facility prior to the outbreak, the agency said officials did visit the site – several years ago – in response to consumer complaints about possible allergens, off-taste and mould in products.

Complaints were made in 2018, 2019 and 2023-24, Ms. Griffin said, adding there was “no causal link between mould and listeria.” The last on-site visit was in 2019.

Inspectors questioned Joriki about the alleged mould, but did not examine the facility for overall compliance – a process known as a licence inspection, which could include reviewing swabs for listeria.

Ms. Griffin said inspectors did not evaluate the company’s procedures or controls for listeria because the mould complaints were unrelated.

Despite these complaints, the plant’s risk level didn’t rise beyond a Priority 3, too far down the list for an inspection in the months before people began getting sick.

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Meanwhile, there were other problems the CFIA knew about.

The Globe reviewed eight lawsuits filed over the past 15 years that involve Joriki. One case in particular shows such problems went beyond consumer complaints, escalating to a product recall in 2009, followed by litigation.

In that case, Mother Parkers Tea & Coffee Ltd. signed a deal with Joriki to produce and bottle iced tea at its other facility in the Toronto area. The drinks were then sold at Tim Hortons locations.

However, when customers began complaining of alleged mould in the iced tea, the two sides entered into a protracted legal battle. Mother Parkers ceased payments to Joriki, prompting Joriki to sue for $3.2-million in lost revenue and damages. Mother Parkers then countersued for $4-million, alleging breach of contract and negligence.

Mother Parkers ordered a series of tests on the iced tea, including from the food safety lab at the University of Guelph. It alleges in court documents there were four types of mould discovered.

Three species weren’t considered harmful. However, Mother Parkers alleges one was a potentially dangerous variety called Cladophialophora bantiana, which “poses a serious health risk to anyone that inhales it, or if it enters the blood stream through open cuts or wounds,” according to the files reviewed by The Globe.

Mother Parkers alleged Joriki “failed to have a program in place to find, prevent and keep under control microorganisms of an undesirable nature,” and “failed to maintain its facilities and equipment used in the manufacture of the product in continuous good working order, and in a clean and sanitary condition.”

“In the interest of the safety of Canadian consumers and in the interest of its Private Label customer, it was necessary to withdraw all products from the market and to cease further production at Joriki.”

Mother Parkers alleged that tests at the facility showed evidence that water in a cooling tunnel, a process used to bring the hot tea down in temperature after being made, was the source of the mould.

Joriki denied the allegations, “and specifically denies the presence of any pathogenic mould in its facility,” the company said in court documents, adding that if mould was present in the product, it “did not originate in the Joriki facility or as a result of any negligence.”

Joriki also sued the maker of the plastic caps on the bottles, alleging the design was faulty and “could have prevented the bottles from sealing properly.”

The dispute was settled in 2015 and the terms are confidential.

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Neither that case, which court documents show the CFIA was consulted about, nor the subsequent mould complaints raised enough concern within the agency to make the company a higher priority for future inspection.

Ms. Griffin said because the iced tea was made at Joriki’s Toronto plant, the matter had no relation to the Pickering facility. And in the cases of the subsequent mould complaints related to products made in Pickering, she said the company was given corrective actions and took the necessary steps.

In its statement to The Globe, Joriki said the CFIA has not taken issue with the company’s procedures before, including when inspectors attended the facility to ask about the mould complaints.

“In no visits to the site by the CFIA prior to the recall had they previously raised any concerns with Joriki’s environmental monitoring programs (including swabbing) or finished product testing,” the company said.

Keith Warriner, a professor of food microbiology and food safety at the University of Guelph, said the mould complaints should have been a red flag for the agency.

The genome sequencing that linked listeria cases to the product 11 months apart also indicates a problem, he said.

“It tells you the listeria was happy to be there – and it was happy to stay there,” Dr. Warriner said.

The full extent of the outbreak will never be known, he said. People who consume tainted products may not become ill enough to go to a hospital, or might assume they had a bad flu. “The upshot is that it’s very underreported,” he said.

After her miscarriage, Ms. Jabeen is now fearful of what she eats and drinks. Nothing she consumed tasted off. “Everything that you believe is good and safe, there’s no basis for that any more,” she said. “I don’t want this to happen to anyone else.”

Her loss isn’t listed as one of the casualties of the outbreak. But according to the family’s Muslim faith, Ms. Jabeen said a baby is considered to have a soul at 17 weeks. The couple obtained a death certificate from their mosque and named the boy Waleed, Arabic for newborn.

The family held a small funeral at a cemetery in Toronto. Mr. Asif dug the grave himself.

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‘You only need one’

The cruel irony in this year’s deadly listeria outbreak is that many people who drank the products involved in the nationwide recall thought they were making a healthy choice. And they likely never considered it could be a problem.

But the CFIA misjudged the risk of the product. Just as listeria can affect meats and dairy, it can also be a serious concern for plant-based milks and cheeses.

Although Tyler Goulet-McMahon, a 28-year-old who lives in the Ottawa area, is not included in the official outbreak numbers, he believes he should be. In the fall of 2023, he was healthy and fit. He rarely needed a doctor, and never took a sick day. “He was just the healthiest guy, he worked out all the time, he was eating super well,” said his wife, Cheyanne.

Mr. Goulet-McMahon said last September, he bought a carton of almond milk to put in his protein shakes. Four days later, he began complaining of flu-like symptoms, then aches and pains. Probably just a bug he picked up from the kids, he thought. But no one else in the house was ill.

Within days he was overcome by high fever and muscle stiffness. At the hospital, doctors felt his neck and suspected bacterial meningitis, a life-threatening condition that can be caused when listeria gets into the brain and spinal cord. It moves with frightening speed and can be fatal within 24 hours.

A spinal tap confirmed their suspicion, and doctors placed Mr. Goulet-McMahon on antibiotics and antifungals. He never received a listeriosis diagnosis. From there the young couple’s life was turned upside down. Soon he was in and out of consciousness and moved to intensive care when he could no longer breathe on his own.

He has no memory of the ordeal until more than a month later when he regained his awareness, awakening in the ICU having lost much of the feeling in his arms and legs.

“At this point, they’re saying he was paralyzed,” Cheyanne recalled. “They’ve never seen anything like this, and they can’t speak to whether he’s going to walk again.”

His arms recovered, but he’s spent much of the past year in physiotherapy, regaining the use of his legs. Nine months later, the couple heard about the recall, checked their past grocery orders, and realized the milk he drank was included.

Now he suspects he is one of the victims, and is upset the problem wasn’t detected sooner. “Why did it take so long, and why were people allowed to continue consuming this for so long,” he said.

Despite the increasing popularity of plant-based milks, there’s very little in the way of published scientific literature on their microbiological quality or safety.

On Oct. 29, the CFIA declared its investigation into the outbreak at Joriki concluded, saying that it had not been able to determine the root cause inside the plant – only that the company hadn’t adhered to proper testing standards and that the CFIA inspector general would be probing the matter further. For now, the facility is shut down for renovations.

In making that announcement, the CFIA also noted that it had in years prior evaluated the risk of plant-based milks and found them to be “generally safe.”

The agency conducted a three-year survey of plant-based beverages between 2019 and 2022 that analyzed nearly 900 samples for the presence of salmonella species and listeria monocytogenes.

The survey, which the agency said was the first of its kind at the time, collected samples from national retail chains and local grocery stores across the country. Neither salmonella nor listeria were found in any of the samples.

“This outbreak shows that new risks can and do emerge as scientific evidence evolves,” the CFIA said in its announcement.

However, according to a leading expert in Europe, there was a problem with the Canadian study.

Dr. Michael Callanan, a microbiologist at Munster Technological University in Ireland, said he was shocked at the details of the outbreak in Canada. “It’s a surprise to see such a failure within the system,” he said.

Dr. Callanan and his colleagues at the university in Cork have been examining the ability of plant-based milks to support the growth of bacteria, including listeria. Their research – first published in the Food Microbiology journal in 2022 and corroborated with a follow-up study this past August – found that listeria grows quickly in plant-based beverages.

Like dairy, which is also susceptible to listeria, a pasteurization step is used to treat plant-based milks before packaging. They are heat-treated to the point of being considered microbiologically safe, but there’s a window during processing for potential cross-contamination: after heat treatment but before the package is sealed.

If listeria gets into the product during that time, it will proliferate. Within 10 hours, Dr. Callanan said, a low number of bacteria can develop into a “very dangerous, infectious dose.”

CFIA’s own assessment of the product is contradictory. The agency characterizes plant-based milks as generally safe, based on its study, but when it comes to its listeria policy it views them as Category 1, which is the highest risk rating. Foods in that category, including dairy and meat, are those that support the growth of listeria under reasonably foreseeable conditions.

While previously there have been recalls related to plant-based products, including a 2022 recall of Silk fortified almond milk in Canada due to spoilage and “non-harmful” microbial contamination, those cases involved bacteria other than listeria.

Dr. Callanan said the problem with the CFIA listeria survey is that it only analyzed samples off the shelf – not the production process itself. In addition, he said, the sample size of the study was too small to be considered representative of the potential for problems in the market overall.

“Checking point-of-sales samples is an interesting exercise, but it doesn’t give you real insight into the danger of an outbreak,” Dr. Callanan said.

“You only need one failing in a plant,” he said. “Where the risk occurs is in the plant.”

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‘It could have been prevented’

Joriki has been making the Silk products in Pickering since 2017. In that time, Danone said it conducted audits on the facility, including reviewing the company’s swabbing results.

“The site had been verified to comply with food safety and quality standards before the listeria outbreak, and environmental test results were reviewed as part of Danone audits,” Danone Canada spokeswoman Jennifer Vincent said in an e-mail.

The Globe asked for details on those audits, but Danone did not provide information about when they took place, how they were conducted or what was found.

Immediately after the recall, evidence of listeria turned up in four places inside the Joriki facility – a holding tank, and around drains near the production line, the CFIA said, citing testing done by Danone in July.

However, all four places are non-food-contact surfaces, meaning they don’t actually touch the plant-based milks. How the listeria got into the products in Pickering remains unknown.

Danone said none of its other production elsewhere in Canada was affected, and that all of its plant-based milk now in stores is being manufactured at other facilities.

“In an abundance of caution, we have conducted thousands of additional quality and safety tests across our entire North American manufacturing network,” Ms. Vincent said.

The Globe asked the CFIA how a product subjected to pasteurization could end up on store shelves tainted.

“Other outbreaks of this nature in Canada and abroad have been attributed to sporadic cross-contamination of the product after pasteurization but before the closing (sealing) of the cartons,” Ms. Griffin said in an e-mail, echoing Dr. Callanan’s theory.

One of the current CFIA inspectors who spoke to The Globe said inspectors can often spot problems just by observing how staff in facilities work, which areas or machinery get sanitized properly and which do not, and by interviewing employees – noticing all the weak links in the cleanliness chain.

Inspections are like having police on the road, the inspector said. People are more likely to comply when there is someone watching.

Mr. Kingston, the retired inspection supervisor, said the fact that the Pickering facility was making a product that required pasteurization – known in the industry as a “kill step” – should have made it more of a priority for inspection.

“If there’s a kill step and packaging process, that should automatically tell you that there needs to be a way of validating that sanitation.”

But with the production facility not considered a priority for inspections, that didn’t occur.

Sylvain Charlebois, a food-safety policy professor at Dalhousie University, was part of a group of academics and other experts convened by the CFIA about a decade ago to evaluate which risk factors would go into the algorithm, and how they could be weighted.

But Prof. Charlebois said he has no idea how the mathematical model was ultimately put into practice.

“It clearly didn’t work,” Prof. Charlebois said.

He said the problem is compounded by a lack of transparency. If the Pickering site, or any other facility in Canada, has not been subjected to formal inspections in a long time, that fact should be out in the open.

“These reports should be made public,” Prof. Charlebois said, including the type of inspections that take place, and which sites haven’t been seen. “There’s just no transparency around visits, or at least telling people when these facilities were visited by the CFIA’s inspectors.”

He isn’t the only one questioning the lack of scrutiny.

Open this photo in gallery:

In July, Natalie Grant’s seven-year-old daughter was struck by high fever and vomiting.

With the situation worsening by the hour, she rushed her daughter, Harper, to the emergency room. That’s where Ms. Grant learned of the listeria outbreak, as word of the recall scrolled across the bottom of a news channel on the television in the waiting room. “She drinks that every day,” Ms. Grant thought to herself.

When they got back to their house in Bowmanville, Ont., Ms. Grant went to the fridge to check the cartons. The codes on the Silk dark chocolate almond milk matched those being recalled. No one else in the family had been drinking it.

When things didn’t improve, they went back to the hospital. By now, Harper was writhing in pain and unable to keep anything down. Doctors diagnosed her with listeriosis, ordered a spinal tap and put her on intravenous antibiotics. Within days, a public-health official contacted Ms. Grant to ask what her daughter had consumed over the past few weeks. Ms. Grant flagged the Silk. She said a public official told her one of the cartons tested positive for listeria.

Ms. Grant read news that people had been killed in the outbreak and, given the tenuousness of her own situation, worried Harper may not survive. It would be another two weeks before her daughter would be discharged.

Many victims are now part of proposed class-action lawsuits against the companies, but those could take years to be resolved.

“I’m supposed to move on,” Ms. Grant said recently. But she can’t accept that there was evidence that listeria was in the facility since the fall of 2023, and it wasn’t found and stopped. Where was the oversight?

“Why are we getting a recall in July of 2024, which is almost an entire year later?” Ms. Grant said. “I can’t get past the fact that it could have been prevented.”

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One last act

Had the listeria been detected sooner, Cale Sampson says his mother wouldn’t have died the way she did.

“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,” he said.

“At least if multiple people are going to die, if pregnant women are going to lose their children, God knows what else, at least there should be a certain degree more accountability than what I feel has occurred.”

“Just watching her deterioration – seeing the decline of her, physically, so rapidly. And seeing the cognitive decline – that was upsetting,” Mr. Sampson said.

He remembers Muriel as a gentle, courageous woman who did her best to raise him as a single parent.

“I love my mom. My mom’s been there for me,” he said. “How much she overcame, to have the ending that she had.”

One of her final acts played a role in helping find the product causing the outbreak. Mr. Sampson’s wife found that Muriel had kept the receipts to all her groceries, which they provided to public-health officials. This evidence may have saved lives, even if it couldn’t save hers.

On the night she was placed on life support, Mr. Sampson leaned in close to his mother and asked her if she wanted to keep fighting. She hadn’t spoken in days, and no one in the room, including the nurse and Mr. Sampson, expected a response. But in that moment, Muriel quietly said, “uh huh.” She wasn’t giving up.

They were the last words she ever spoke.

A few nights later, Cale held his mom’s hand as she died.