The government food safety watchdog's handling of the horse-meat crisis was slow, badly executed and indecisive, the first investigation into the scandal has found.
The Food Standards Agency (FSA) reacted with a "hesitancy" that stemmed, in part, from "a lack of appreciation of the potential impact" of the first identified case of horse meat being substituted for beef in the UK in February, an independent report concluded.
Once the problem was identified, FSA staff - a number of whom were found to have "limited experience" of major food-safety incidents - took a "wait and see approach" rather than decisive action, said the report's author, Professor Pat Troop, the vice-chairwoman of Cambridge University Hospitals and a former deputy chief medical officer for the National Health Service.
"The reasoning appeared to be that there was only one company with a product with significant contamination, so it may be a 'one-off'," said Prof Troop, who was commissioned by the FSA. "The alternative approach might have been 'there is one major well known company involved … so might others be?'"
She added: "In general, it has been shown that it is wiser to work to the latter and scale up accordingly, otherwise an organisation can find itself running to catch up."
Mary Creagh, the shadow Environment Secretary, said the report showed that the Government had hoped the horse-meat crisis would simply go away. "[The Farming minister] David Heath told me we must be very careful not to talk down the British food industry when I brought it up. The Government just hoped it would all go away, taking a 'a wait and see approach' when it should have taken pre-emptive action."
Ms Creagh, the Labour MP for Wakefield, also criticised ministers for "fragmenting" regulation of the food industry, which she said slowed down its response in those "critical early days".
Professor Troop found that the crisis was exacerbated by the Government's decision in 2010 to transfer responsibility for food labelling and authenticity from the FSA to the Department for Environment, Food and Rural Affairs (Defra) - but only when it was not a safety matter. These changes caused a good deal of confusion, with many parties unsure whether the FSA or Defra was in charge, Professor Troop added. Her report called for better use of intelligence across the food industry, with local authorities, government departments and the FSA developing an intelligence management system to identify future risks. It also implied that the FSA was not very effective at securing evidence that could be used to identify and prosecute criminals.
"The incident demonstrated the limitations in the powers of the FSA, for example in power of entry into food premises, which could lead to loss of evidence if papers are moved elsewhere. These powers should be reviewed to ensure action can be taken in a timely way," the report said. "Although generally forthcoming in this incident, when investigations of this size, scale and complexity are required any lack of co-operation could have had a significant detrimental impact."
Ms Creagh said: "The weaknesses this report highlights may mean that no prosecution is ever brought for what was, probably, the largest consumer fraud ever committed against the British public."
The FSA, which quietly slipped out the report at the end of the working day on Friday, declined to comment on its findings, although it is expected to address the issues in the coming days. Shoppers have dramatically changed the types of food they buy since horse DNA was first found in burgers on sale in supermarkets such as Tesco on 16 January.