The much-anticipated internal Switkowski Report into the processes surrounding the Essendon doping scandal has been released revealing 'institutional failures' but no blame for specific individuals.
The report by Dr Ziggy Switkowski was commissioned by the club in the wake of a supplements program which led to an explosive ASADA investigation.
While the report admitted that player conditioning process had varied sharply since 2011 and there were concerns over the methodology employed, the publicly released version did not attribute blame to either suspended High Performance Manager Dean Robinson or controversial sport scientist Stephen Dank.
The report admitted it was constrained by the parallel investigation being undertaken by ASADA.
The key findings include a failure in structure and accountability at the club, failure of risk management processes and the sidelining of key medical staff, including Dr Bruce Reid.
"The arrival of confident, opinionated staff was not accompanied by a simultaneous strengthening of the processes within Football Operations, or by extra vigilance by senior management," read the report.
"Their mission was to increase strength of players primarily through a revised weights program. This quickly morphed into a larger effort involving allegedly leading practices in sports medicine. This fitness strategy was appropriately bounded by instructions that all practices be compliant with the relevant codes.
"However, the supplement plan, if one existed, evolved and probably never reached a coherent, consistent shape. Innovative supplement practices and compounds soon appeared - somewhat predictably given the mandate of the High Performance team. The leaders of the program insist their methods were always legal and compliant, and that conviction prevailed and still prevails within the football department.
"But a number of management processes normally associated with good governance failed during this period, and as a result, suspicions and concerns have arisen about the EFC.
"In particular the rapid diversification into exotic supplements, sharp increase in frequency of injections, the shift to treatment offsite in alternative medicine clinics, emergence of unfamiliar suppliers, marginalization of traditional medical staff etc combine to create a disturbing picture of a pharmacologically experimental environment never adequately controlled or challenged or documented within the Club in the period under review.
"Compliance rules existed but normal controls during an abnormal period were insufficient to check the behaviours of some people who may have contravened accepted procedures, and the CEO and the board were not informed.
Dank was not interviewed for the report and neither was Robinson.
Club chairman David Evans admitted to institutional failures at the club.
"There will be some changes as far as the board agenda. That will include player welfare and will include dialogue with club doctor," Evans said.
"The use of external doctors was not known to the club or to the medical staff at the club."
Evans admitted that given the issues had occurred with him in charge, it was appropriate that his chairmanship go to a vote at the earliest possible opportunity.
"The buck does stop with me," he said. "I'm chairman of the board and this happened on my watch.
"I'll go to an election at the earliest possible time in November this year."
And as for Robinson not being interviewed, Evans would only say: "There was some confusion around whether Dean was available to be interviewed and I'll leave it at that."