that the BWA was cautionary only, reported the advisory at roughly hourly intervals, beginning at 1:30 p.m., rather than more rapidly as they later stated they might have if the import of the announcement had been made clear to them at the time. As a result of the limited distribution of information regarding the BWA, much of the community remained unaware of the Boil Water Advisory until days after its May 21 issuance. Around the time the BWA was first being broadcast, David Patterson (the Assistant Director of Health Protection at BGOSHU) contacted the MOE's Spills Action Centre (SAC) to officially report an E. coli outbreak in Walkerton. Paul Webb, the SAC employee taking Patterson's phone call, mentioned that they had previously been contacted by an anonymous source (Robert McKay) about the quality of water coming out of the Walkerton PUC. The men discussed the PUC's assurances that their water was safe, and the call ended with no action. Shortly afterward, however, Patterson contacted Stan Koebel, the manager at the Walkerton PUC again. Koebel expressed dismay at the Boil Water Advisory and the fact that the PUC had not been notified of it beforehand. He asked Patterson's advice for the best next steps to take; Patterson suggested increasing chlorination levels in the system. The same afternoon, the Spills Action Centre contacted Stan Koebel (the PUC manager) directly to discuss the ongoing events; Koebel once again failed to mention prior known adverse testing results. In later testimony, he acknowledged that this had been a deliberate omission; the O'Connor report concluded that Koebel had been hoping that when new samples were collected on May 23, they would test clean and lift the burden from his shoulders. Stan and Frank Koebel again spent part of their day on May 21 flushing the system. At 2:30 p.m. on May 21, the BGOSHU convened a strategic response team to handle the outbreak. After discussion, the team decided to directly notify at-risk or involved institutions, including hospitals, of the Boil Water Advisory. The Walkerton hospital received its notification at 3:30 p.m. that day. Prior to this, and despite numerous contacts with BGOSHU staff, hospital personnel had not been aware of potential danger from Walkerton water; in some cases hospital personnel had been told specifically that water was not the cause of the outbreak. The Ministry of the Environment nominally received notification of the outbreak from a