The Bombers asked former Telstra CEO Dr Ziggy Switkowski to review its internal governance, practices and procedures in the wake of the Australian Sports Anti-Doping Authority's investigation into the club's supplements program between November 2011 and August 2012.
Switkowski's key recommendation was that "pioneering work with supplements and exotic treatments should be left to the Australian Sports Commission.
Click here for the full Switkowski report
"At a club level, this is not an area for risk management but for zero tolerance.
"A club's pharmacology skills should not normally be independently and secretly developed as a source of competitive advantage. And an arms race for the most sophisticated molecules must be prohibited."
He found the club was "damaged but not broken", and that there was a lack of clarity over who was in charge of the football department.
"There were two separate roles, with fuzzy lines of responsibility," Switkowski said.
"The responsibilities of two key staff overlapped, and the new fitness team was able to largely ignore their attempts at direct management. Added to this is a senior coach in his first coaching role."
From 2011 to 2013 - the timeline of events at Essendon
Evans confirmed that the two staff members were current general manager of football Danny Corcoran and former football manager Paul Hamilton.
Switkowski said the CEO must be accountable for everything that happened at the club.
Evans told a media conference he was "deeply sorry" that the breaches happened on his watch, and he said he would put his leadership of the club to the test by going to an election in November.
He said changes to the club's governance had already been made, and more would follow.
Evans said he could not guarantee that heads would not roll before the conclusion of the ASADA inquiry, "but at the moment we stand by our people who are at the club at the moment".
"This is an uncomfortable report and it probably should be. I think that's a good thing for us because this is something we need to deal with in looking at the procedures have let us down.
"We have got the help of two pharmacological experts. They have been advising the board for the past three months and we are getting more and more confident … that there was nothing banned that was given to our players."
Evans confirmed that veteran club doctor Bruce Reid had written a letter about the controversial supplements program: "One of the confusing things here is where that letter went, and clearly that letter didn't go to where it should have. That's something we'll have to deal with."
He said controversial sports scientist Stephen Dank, who oversaw the supplements regime, was not interviewed by Switkowski.
Switkowski found that 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".
A mission to increase strength through an enhanced weights program had morphed into a larger effort involving allegedly leading practices in sports medicine.
"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, marginalisation of traditional medical staff, etc, combine to create a disturbing picture of a pharmacologically experimental environment never adequately controlled or challenged or documented."
AFL CEO Andrew Demetriou told reporters in Sydney, "I've said from day one that David Evans the chairman has been absolutely brilliant throughout this whole process.
"He's never shirked the responsibility. He's the chairman, he's uncovered things that he wasn't comfortable with, he contacted the AFL and sought immediate intervention and called for the ASADA ienquiry.
"From day one he's insisted that everyone at that football club cooperate. That's exactly what's happened."
Demetriou received a full copy of the Switkowski report more than a week ago and said it should act as a wake-up call to all clubs across all codes about their practices and accountability.
"This report does highlight some deficiencies in some accountability and some processing and again, you need to put that together with the ASADA investigation when it's finished."
"At a club level, this is not an area for risk management but for zero tolerance.
"A club's pharmacology skills should not normally be independently and secretly developed as a source of competitive advantage. And an arms race for the most sophisticated molecules must be prohibited."
He found the club was "damaged but not broken", and that there was a lack of clarity over who was in charge of the football department.
"There were two separate roles, with fuzzy lines of responsibility," Switkowski said.
"The responsibilities of two key staff overlapped, and the new fitness team was able to largely ignore their attempts at direct management. Added to this is a senior coach in his first coaching role."
From 2011 to 2013 - the timeline of events at Essendon
Evans confirmed that the two staff members were current general manager of football Danny Corcoran and former football manager Paul Hamilton.
Switkowski said the CEO must be accountable for everything that happened at the club.
Evans told a media conference he was "deeply sorry" that the breaches happened on his watch, and he said he would put his leadership of the club to the test by going to an election in November.
He said changes to the club's governance had already been made, and more would follow.
Evans said he could not guarantee that heads would not roll before the conclusion of the ASADA inquiry, "but at the moment we stand by our people who are at the club at the moment".
"This is an uncomfortable report and it probably should be. I think that's a good thing for us because this is something we need to deal with in looking at the procedures have let us down.
"We have got the help of two pharmacological experts. They have been advising the board for the past three months and we are getting more and more confident … that there was nothing banned that was given to our players."
Evans confirmed that veteran club doctor Bruce Reid had written a letter about the controversial supplements program: "One of the confusing things here is where that letter went, and clearly that letter didn't go to where it should have. That's something we'll have to deal with."
He said controversial sports scientist Stephen Dank, who oversaw the supplements regime, was not interviewed by Switkowski.
Switkowski found that 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".
A mission to increase strength through an enhanced weights program had morphed into a larger effort involving allegedly leading practices in sports medicine.
"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, marginalisation of traditional medical staff, etc, combine to create a disturbing picture of a pharmacologically experimental environment never adequately controlled or challenged or documented."
AFL CEO Andrew Demetriou told reporters in Sydney, "I've said from day one that David Evans the chairman has been absolutely brilliant throughout this whole process.
"He's never shirked the responsibility. He's the chairman, he's uncovered things that he wasn't comfortable with, he contacted the AFL and sought immediate intervention and called for the ASADA ienquiry.
"From day one he's insisted that everyone at that football club cooperate. That's exactly what's happened."
Demetriou received a full copy of the Switkowski report more than a week ago and said it should act as a wake-up call to all clubs across all codes about their practices and accountability.
"This report does highlight some deficiencies in some accountability and some processing and again, you need to put that together with the ASADA investigation when it's finished."
