While Legionella was also found in cooling towers of three nearby buildings, the high attack rate within the Seven Oaks facility and the connection of all the cases to the building argues strongly that the release of Legionella from the Seven Oaks cooling tower was the cause of this outbreak. [...] For purposes of this report card, the Panel looked specifically at the systems’ ability to: 1. Care for patients 2. Provide a coordinated response 3. Protect health care workers and prevent the spread of disease 4. Make the diagnosis 5. Find the source of the bacteria 6. Share information and communicate Report of the Expert Panel on the Legionnaires’ Disease Outbreak 10 December 2005 Report Card: [...] The Office of the Chief Coroner Because of the number of deaths, the Office of the Chief Coroner became involved early in the outbreak, and played a key role in helping to diagnose the cause of the outbreak. [...] Report of the Expert Panel on the Legionnaires’ Disease Outbreak 15 December 2005 Report Card: Progress in Protecting the Public’s Health Ministry of Health and Long-Term Care At the provincial level, the Public Health Division, including the Emergency Management Unit (EMU), also had procedures in place and those were followed. [...] Most of the organizations involved in the outbreak – with the exception of Seven Oaks and the Central Public Health Laboratory – managed their role in the outbreak using existing staff.