NSW Health made a number of serious mistakes of its handling of the Ruby Princess including the delay in sending swabs for COVID-19 testing and assessing the cruise ship as low risk.

A special commission of inquiry investigated the decisions made by Carnival Australia, NSW Health and Federal Government agencies into what became on of the biggest causes of coronavirus infections in the state, with 22 deaths and over 700 cases.

Commissioner Bret Walker submitted his 315-page report to the NSW Government today and found all passengers onboard should have been tested for COVID-19.

In his report, Mr Walker said NSW Health should have ensured that cruise ships were aware of the change to the definition of a “suspected case” for COVID-19 made nine days before the Ruby Princess docked in Sydney on 19 March.

“This would have resulted in the identification of such cases on the Ruby Princess. 101 persons fell within the suspect case definition by 18 March, and 120 by the time the ship docked,” the report says.

“NSW Health should also have ensured that such persons were isolated in cabins. These were serious mistakes by NSW Health.”

The report also said the failure of the collection of swabs by an onboard health assessment team “was a serious failure by NSW Health.”

After the report was released, Princess Cruises issued a statement welcoming the report and said the line “again expresses profound sorrow at the impact COVID-19 has had on Ruby Princess’s guests, crew and their families. Our hearts go out to everyone who has been affected, particularly those who lost loved ones.”

The statement went on: “The Commission’s report confirms that none of our people — the Captain, the ship’s doctor, or members of our shore side port agency team — misled public authorities involved in Ruby Princess being permitted to disembark guests on March 19.

“This finding is of great importance to us because it goes to the integrity of our people. In our more than 20 years in Australia, we have always sought to cooperate honestly and professionally with officials in accordance with the regulatory environment.

“We acknowledge the Commission’s specific comments about Carnival and we will consider these comments to the fullest possible extent.

“Princess Cruises also welcomes the Commission’s attention to improving information sharing and coordination among government agencies in the future. In our submission to the inquiry, we agreed that this area deserved consideration. We look forward to collaborating with government agencies and industry peers to improve these systems.”

Mr Walker’s report was careful not to make recriminations over the incident. Indeed, the commissioner went out of his way to explain the circumstances under which the main players were forced to make what turned out to be life-and-death decisions.

“Some of these estimable individuals, as the evidence showed, remain in charge of weighty aspects of the State’s frontline response to the pandemic. I have to say that my confidence in their good faith and skilled diligence in these continuing efforts was not dented by the criticism I have expressed about the Ruby Princess episode,” Mr Walker said.

“Everyone makes mistakes, and when we judge one another we should bear that in mind. As Commissioner in this Inquiry, I have been made sharply aware that, while we all make professional mistakes, the burden and stress created by life-and-death consequences in some but not all professions should engender sympathy and regard for those (like the Expert Panel in this case) whose duties are carried out under the weight of such consequences.”

The commissioner’s key findings are:

The Ruby Princess had fewer swabs on board when it departed Sydney on 8 March than it ultimately needed for testing under the 9 March Enhanced Procedure. No criticism is made, however, of Dr von Watzdorf (ship’s medical officer) in relation to her attempts to secure a supply of swabs for the ship either before or during the 8 March voyage.
Dr von Watzdorf’s response to being asked whether health assessment for respiratory illness was “free” was truthful.
No criticism is made of Mr Little (Carnival Australia’s guest experience senior vice president) for not informing NSW Health of what he perceived as the “significant spike” in ARI/ILI numbers on the Ruby Princess on 17 March. The significant increase in numbers was conveyed to NSW Health by provision of the ARD Log.
Carnival should have ensured Dr von Watzdorf was made aware of the change to the CDNA Guidelines for a “suspect case” of COVID-19 on 10 March. Carnival should have ensured that passengers and crew on the ship were informed that there were suspect cases of COVID-19 on board. Those persons who fell within the suspect case definition should have been required to isolate in their cabins.
Dr von Watzdorf should have notified NSW Health of the additional passengers and crew diagnosed with an ARI/ILI on 18-19 March. This was an inadvertent oversight on her behalf, rather than a failure to comply with a requirement.

The inquiry said it had been advised of 28 deaths associated with passengers from the ship with 20 in Australia and an additional eight in the United States.

The commission said that 663 Australian passengers contracted COVID-19 with 191 crew members were also infected.

Premier Gladys Berejiklian said: “In the public interest and for full transparency I am releasing it immediately.

“I have just received the report. I will read it over the weekend and respond early next week.”

Princess’s statement continued:

“Our overriding objective is to ensure cruising is a safe and enjoyable pastime for the millions of people who value exploring the world by sea as their preferred holiday choice.

“Princess Cruises has developed strong relationships with our guests, travel agents and other stakeholders in Australia and over decades we have also worked closely with the Australian Government, State Governments and their agencies on many initiatives to build and invest in the cruise industry in Australia.

“We will now take some time to consider the Commission’s findings. In the light of ongoing legal proceedings, we are not able to add to these comments at this time.”

A homicide investigation is also being carried out into the incident, which will report on any charges the Police Commissioner believes should be brought.

You can read the report here:

https://www.dpc.nsw.gov.au/assets/dpc-nsw-gov-au/publications/The-Special-Commission-of-Inquiry-into-the-Ruby-Princess-Listing-1628/Report-of-the-Special-Commission-of-Inquiry-into-the-Ruby-Princess.pdf