The Emergency Services Agency has a culture of blame and fear which affects the health and wellbeing of its staff, while its executives do not trust each other, an external review has found.
The snap review identified examples of agency executives bullying, blaming, withholding information and undermining decisions, and said a "cultural shift" was needed.
Confusion about the responsibilities of roles from the commissioner down is found across the agency, while the role of assistant commissioners was particularly unclear.
The agency's executive staff do not communicate effectively and staff were reluctant to report poor behaviour out of fear of being victimised for speaking up, the review found.
"The executive group are not seen by the workforce, or themselves, as a unified team. Trust between executives has been seriously eroded," the review said.
Justice and Community Safety Directorate head Richard Glenn in March ordered the review of the agency, which manages firefighting, ambulance and emergency response services in the territory.
Former Ambulance Victoria chief executive Tony Walker led the review alongside the ACT government's office of industrial relations and workforce strategy.
Professor Walker's report said stakeholders had described a chaotic environment with a consistently reported lack of trust among executive staff.
"Fundamentally, a cultural shift is needed, from a culture of blame and fear to one of trust and collaboration. This will not be easy," Professor Walker's report, seen by The Canberra Times, said.
The review made 18 recommendations, including the establishment of an implementation oversight committee, executive coaching for all senior staff and a facilitated leadership reflection process.
"Examples of poor behaviour, such as withholding information, undermining decisions, blaming and bullying, including by exclusion, were identified," the report said.
Mr Glenn accepted all the recommendations and on Tuesday afternoon told staff he would establish the oversight committee and request a detailed implementation plan.
The review also recommended the agency clarify executive level roles and responsibilities and that all executive staff members should have active performance agreements. The agency should also develop a motto.
"Stakeholders consistently reported behaviours by executives which are not aligned with [ACT public service] values," the report said.
"There is an apparent culture of blame and fear within the organisation which is having an impact on the health and wellbeing of the workforce.
"The executive are not unified, and reportedly do not model collaboration. In some cases, examples were given where they appear to actively inhibit co-operation between services and with enabling services.
"The executive, as a cohort, does not communicate effectively."
The review recommended first establishing an oversight committee to manage improvements in the agency.
"The review heard that there are concerns from some about accountability and follow through for decisions and initiatives," the report said.
"There appears to be a practice of verbal agreements and decision-making, which reduces staff confidence in decisions."
The review was completed by June 30 and handed to Mr Glenn, who told the agency's staff on July 4 he would release more information about an "action plan" shortly.
The Transport Workers' Union, which represents paramedics, and the United Firefighters Union had called for the review report to be released publicly.
Emergency Services Minister Mick Gentleman had said in answer to a Legislative Assembly question on notice about 40 current Emergency Services Agency staff had attended consultation sessions.
The report said the review team had consulted with 65 people, including Emergency Services Agency executives, Justice and Community Safety Directorate executives, current and former agency staff, agency volunteers, unions, volunteer associations and current and former advisory council members.
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