Travel firm Thomas Cook's dealings with the family of two children killed by carbon monoxide were often ill-judged, an independent review has found.
Bobby and Christi Shepherd, aged six and seven, died at the Louis Corcyra Beach Hotel, in Corfu, in October 2006.
The review said the deaths were compounded by Thomas Cook's reaction.
Thomas Cook said the report, which also said parts of the firm protected costs ahead of customer experience, made for "uncomfortable reading in parts".
The review into the firm's customer health and safety procedures and crisis management was carried out by former Sainsbury's chief executive Justin King.
It did not re-examine the events of the children's deaths.
Approaches to the family were "intermittent, sometimes ill-timed and often ill-judged", said the report.
Sometimes the family's approaches to the company got no response at all, it said.
The report said "significant shortcomings" in the implementation of the travel company's health and safety strategy had been identified.
"Decisions were often not taken in the thoughtful and caring way you would expect from a company such as Thomas Cook," said Mr King.
He said parts of the company such as the airline and Destination Management had a tendency "to protect cost rather than maximise the customer experience".
Analysis by Kamal Ahmed, BBC business editor
In an era when there is considerable suspicion about the motivation of businesses, the ability of a company to react to a crisis in a way that reveals it to be run by human beings rather than faceless chief executives is of paramount importance.
Every company chief executive should read Justin King's report. And reflect on now many of the problems he has identified are also true of the businesses they run.
Peter Fankhauser, chief executive of Thomas Cook, said: "It took us nine years to correct the mistakes of the past and to do what everyone would have expected of us; treat the family with the respect and empathy they deserve.
"We had to learn from this tragedy and do things differently, and this remains our commitment."
He said he the review would "serve as a catalyst" for the changes the company was making.
An inquest into the children's deaths earlier this year found the tour operator had "breached its duty of care", and that the children, from Horbury near Wakefield, had been unlawfully killed.
Mr King's review said, including Bobby and Christi, there had been five recorded package tour deaths attributed to carbon monoxide in the UK travel industry since 1988.
The report made a series of recommendations including:
- The Thomas Cook Group should increase significantly the internal resource allocated to health and safety
- It should create a confidential health and safety whistle-blowing line for employees and suppliers
- The company should include a section on carbon monoxide risks and safety within its brochures and website
- There should be a full briefing on carbon monoxide risk for all the company's personnel at resorts and destinations
- An affordable and portable carbon monoxide monitor should be available for travellers to buy via the company website
Thomas Cook said it would work through the report's recommendations with a view to implementing them over the next 18 months.
Sharon Wood and Neil Shepherd, Christi and Bobby's parents, welcomed the report and said: "It is a move in the right direction and the next step in what has been a long, hard fight for justice.
"Our hope is that we can bring about change that will dramatically reduce the number of deaths and injuries from carbon monoxide, both in the UK and abroad."
Mary Creagh, the Labour MP for Wakefield said the report was a "damning assessment of Thomas Cook's treatment of Christi and Bobby's parents in the nine years since their tragic deaths".