water at walkerton was safe to drink. however, as the outbreak grew in severity the two were eventually part of the criminal investigation into the incident, and, as a result, both would eventually plead guilty to a charge of common nuisance through a plea bargain. in their plea, they admitted to falsifying reports and frank admitted to drinking on the job, as a beer fridge did exist at the facility. stan and frank koebel were both formally sentenced on december 20, 2004; stan to one year in jail, and frank to nine months house arrest. the ontario clean water agency was put in charge of the cleanup of walkerton's water system after the outbreak. the incident led to a broader environmental consciousness in ontario, which has been linked to the change in ontario electricity policy to phase out coal. an inquiry, known as the walkerton commission led by court of appeal for ontario associate chief justice dennis o'connor, wrote a two-part report in 2002. part 1 was released in january 2002. the walkerton report, part one, described events in the community and a series of failures, both human and systemic, that led to contamination of the water supply. the report made recommendations based on the circumstances of the outbreak. it estimated that the walkerton water contamination cost a minimum of c$64.5–155 million and laid much of the blame at the door of the walkerton public utilities commission: the walkerton public utilities commission operators engaged in a host of improper operating practices, including failing to use adequate doses of chlorine, failing to monitor chlorine residuals daily, making false entries about residuals in daily operating records, and misstating the locations at which microbiological samples were taken. the operators knew that these practices were unacceptable and contrary to ministry of environment guidelines and directives. the ontario government of mike harris was also blamed for not regulating water quality and not enforcing the guidelines that had been in place. the water testing had been privatized in october 1996. part 2 of the report made many recommendations for improving the quality of water and public health in ontario. part two discussed water safety across the province and the steps needed to prevent similar tragedies. it made ninety-three recommendations. all of its recommendations have been accepted by succeeding governments of the province. the recommendations have also influenced provincial policies across canada. key recommendations touched on source water protection as part of a comprehensive multi-barrier approach, the training and certification of operators, a quality management system for water suppliers, and more competent enforcement. in ontario, these requirements have been incorporated into new legislation. contributing causes physical well 5: shallow depth of the well, its being surrounded by fractured bedrock, and its physical location near a source of cattle manure runoff all contributed to well 5 being unusually susceptible to contamination chemical inadequate chlorination of well 5's water (as well as water throughout the walkerton puc system) meant that, once it was contaminated by bacteria such as e. coli, it remained so. organizational negligence public utility commission staff: inadequate training and continuing education among staff of the walkerton puc meant that those responsible for the safety of the area's water were not equipped to make informed decisions in this area the walkerton puc had a long-term history of failing to abide by the minimum water testing and treatment requirements inadequate monitoring of system water: puc staff regularly collected fewer samples than required, and collected them from improper areas of the system. both of these practices were known to potentially lead to false-negative contamination results. similarly, puc staff generally failed to perform chlorine residual monitoring tests as often as necessary, and often performed them improperly when they did perform them. improper chlorination: though the ministry of the environment had repeatedly reminded the puc of the importance of maintaining the system at a 0.5 mg/l chlorine residual after 15 minutes, puc staff relied on their personal judgment that this standard was unnecessary due to the water's inherent quality and chose to chlorinate the system to a lesser level, partially in response to community complaints that the system's water tasted of chlorine. public utility commissioners (two elected, one the town's mayor serving ex oficio): public utilities commissioners should have been responsible for hiring and maintaining informed and capable puc staff, beginning with senior management; this was neglected in walkerton, as the commissioners felt that their responsibilities encompassed only "budgeting and financial aspects of the operation". commissioners relied on puc manager stan koebel to make policy and inform the commission of water quality-related events of interest, even when commissioners were or should have been aware of such information and responsible for policy-setting. commissioners also failed to review whether koebel was performing these aspects of his job adequately. commissioners were offered no education on the topic of water safety, and none was required of them in order to be elected or to serve. commissioners typically did not consider this knowledge a requirement for doing their jobs, even when they had access to relevant resources. negligence by individuals falsification of reports: puc staff regularly entered chlorine residual results on log sheets that did not reflect actual testing results or that represented testing that had never been performed at all. stan koebel, general manager of the walkerton puc: koebel knowingly failed to notify the bruce-grey-owen-sound health unit when he became aware on may 15 that water from his system was heavily contaminated. prior to public health investigators determining that the water system was a likely cause of the outbreak, koebel communicated to the health unit the false impression that the water system had been checked and was safe. in media the lessons learned from this incident were described by kim vicente in his book the human factor. a 2005 cbc television docudrama called betrayed was based loosely upon the walkerton e. coli outbreak. on may 11, 2018, the toronto star reported that following 18 years of suffering robbie schnurr had doctors assist him in ending his life due to illness caused by the outbreak. twenty-two of the children who became sick in 2000 acquired permanent kidney damage.