The Bluestone Review, commissioned by Swimming Australia following Australia's worst Olympic swimming performance in 20 years, found that a culture existed within the swim team which "did not appear to assist or support high-level performance for most people."
It says incidents of peer intimidation and hazing went unaddressed by coaches and alienated the lower profile swimmers, who felt the emphasis on gold medal success caused anxiety in the camp.
The report also described standards and accountability as "too loose", and that a number of situations "compounded in significance as no one reined in control."
"There were enough culturally toxic incidents across enough team members that breached agreements (such as getting drunk, misuse of prescription drugs, breaching curfews, deceit, bullying) to warrant a strong, collective leadership response that included coaches, staff and the swimmers. No such collective action was taken," the report said.
Swimmers described these Games as the 'Lonely Olympics' and the 'Individual Olympics'. There was not much connection between groups of athletes, or between athletes, staff and coaches other than what was engineered reactively.
There was no collective voice back to the media on behalf of the swimmers on either performance or personal issues, and as the first week unravelled, the swimmers felt undefended, alone, alienated and that no one 'had their backs' this year.
They did not feel part of a galvanised community or that they were in partnership. They felt confused and unsupported by their own team in some cases and not supported well enough by SAL, even from the stands.
Some individual incidents of unkindness, peer intimidation, hazing and just ‘bad form’ as a team member that were escalated to personal coaches were not addressed and had no further consequence.
One athlete reported that ‘I felt awkward, felt weird; I just kept my head down. I didn't know how to handle it; I just avoided it'.
The report outlines an Olympics campaign that deteriorated as leading stars failed to win expected gold medals, with no plan in place to deal with the losses.
Athletes said wins were praised, but anything less was met with silence.
"It seems that morale began to drop once the team started to lose in the first few days," the report said.
"People felt the failure very keenly while they were still in the midst of performance. It was a contagious feeling that had a high impact on the mood.
"Some athletes let their emotion play out as bravado, withdrawal, disinterest and sulking.
"This tension was not nipped in the bud ... indeed it was heightened with scuttlebutt and assumptions and diagnoses of doom from the media and the pool deck; things aren't going well."
It says athletes felt disconnected from the head coach and issues were "'managed quietly' rather than brought to a head."
The report recommends a stronger ethical framework of what Swimming Australia stands for, to update internal codes of conduct and create better processes for managing issues around standards and expectations.
It also recommended head coach Leigh Nugent be sent on an "an intensive coach-the-coach leadership program" for up to six months.
"There is a dire need to develop and enable leadership throughout swimming, and to orient people to consider leadership as personal, not just functional," it said.
'Make the hard call'
Australian swimming legend Geoff Huegill says the review does not come as a shock and says the onus now lies with head coach Nugent to discipline any offenders.
"The findings definitely don't surprise me," Huegill told Fox Sports News.
"We've definitely been discussing it once the games were over and where things went wrong and what needed to be done.
"I think the biggest thing to look at is the coaches, because the coaches have to take responsibility for this.
"If the coaches don't take responsibility for these athletes and for the leadership that needs to be shown, then they're ultimately just as much to blame as the athletes.
"If you're in a team environment, everyone needs to huddle together, pull together and cheer together. You can't just have people going in left, right and centre doing their own thing.
"Now that we've got an official report, the most important thing now is to make sure the proper actions are taken forward.
"At the moment [Nugent is] a great coach and a great leader, but this will be the true test of his characteristics.
"Being head coach, at the end of the day, he's going to have to make tough decisions. He's not going to please everyone.
"You need to make the hard call and discipline those who haven't been abiding by the team rules."
The Australian Sports Commission is also waiting on an 80-page report from former federal sports minister Warwick Smith on possible governance reforms in Australian swimming.
High performance review
Meanwhile, the Australian Sports Commission (ASC) has welcomed the Independent Swimming Review's separate report into swimming, with a focus on high performance, governance and administration.
The report cited Swimming Australia's "non-strategic business practices and a governance system that did not operate as well as it should", and says strategic planning was not followed or assessed in the lead-up to the London Games.
Read the Independent Swimming Review's final report here
"Over much of the Olympic cycle the high performance system, athletes, service providers, coaches, AIS, SIS/SAS network and members of SAL did not have a clearly visible national direction to guide them in applying a vast range of resources in a way that could best ensure success in the context of elite sport," the report said.
ASC chairman John Wylie said the Independent Swimming Review's final report would help the decision making process for future investment in sports.
"I am particularly pleased that the panel has made some clear recommendations around governance as this is an area that the ASC is placing significant focus on as part of its new strategic direction," Wylie said in a statement.
"Swimming Australia has already commenced recruitment for a new high performance director and has also taken steps to improve its relationship with key stakeholders like the Australian Swimmers Association.
"This report is a clear message to Swimming Australia to continue its reforms to enable it to return to the top table of international swimming."