The New South Wales health department made a number of serious mistakes in the process of allowing the Ruby Princess cruise ship to disembark in Sydney, but there are no “systemic” failures to address, special commissioner Bret Walker has found.
In his 320 page report on the inquiry into the Ruby Princess — which was delivered to the state government on Friday afternoon — Walker also asserted that the Australian Border Force and the Department of Home Affairs “do not bear any responsibility for the Ruby Princess mishap”.
More than 2600 Ruby Princess passengers were allowed to disembark at Circular Quay on March 19. Since then, the ship has been linked to hundreds of COVID-19 cases and 28 deaths, including eight in the US.
Walker found that while NSW Health officials had “adequately” attempted to protect the public against COVID-19 on cruise ships, “their attempts sadly miscarried in this event”.
NSW Health should have ensured cruise ships, including the Ruby Princess, were aware of the change to the definition of a “suspect case” for COVID-19 made on March 10, the commissioner found.
“This would have resulted in the identification of such cases on the Ruby Princess — 101 persons fell within the suspect case definition by March 18, and 120 by the time the ship docked,” the report said.
The department also should have ensured that suspected persons were isolated in cabins, and an onboard health assessment team should have collected swabs.
“The delay in obtaining test results for the swabs taken from the Ruby Princess on the morning of 19 March is inexcusable. Those swabs should have been tested immediately,” Walker wrote.
“In light of all the information the [NSW Health] expert panel had, the decision to assess the risk as ‘low risk’ – meaning, in effect, ‘do nothing’ – is as inexplicable as it is unjustifiable. It was a serious mistake.”
Walker noted that had NSW Health senior epidemiologist Kelly-Anne Ressler “not failed to update the epidemiological criterion”, the expert panel may not have assessed the ship as low risk. The panel also “failed to realise and act” on information that the risk of COVID-19 on the ship increased by the presence of overseas passengers.
Allowing passengers to disembark and then travel interstate and internationally to return home “did not appropriately contemplate or comply with the terms of the Public Health Order”, and NSW Health should have arranged accommodation for all passengers to quarantine for 14 days, Walker found.
However, the “imperfections” in NSW’s public health work “should not be taken as damning condemnation of the individual public servants involved”, as the mistakes weren’t necessarily characteristic of the public servants.
“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,” the report said.
“Everyone makes mistakes, and when we judge one another we should bear that in mind … 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.”
Walker found that although NSW Health made several major mistakes, there were no “systemic” failures to address, and that NSW Health public health physicians “relied on the best science”, and were “diligent and properly organised”.
Commonwealth ‘fly in the ointment’
While many individuals and agencies were a “great assistance” during the inquiry, the commonwealth and its immunity from appearing before the inquiry was “the one fly in the ointment”, Walker said.
“A summons to a commonwealth officer to attend and give evidence about the grant of pratique for the Ruby Princess was met with steps towards proceedings in the High Court of Australia. Quite how this met the prime minister’s early assurance of full cooperation with the commission escapes me,” he said.
“This waste of time and resources, when time, in particular, was always pressing, was most regrettable. As the quality and helpfulness of the voluntary submissions by the commonwealth demonstrated, there was no problem of resources or governmental embarrassment conducing against the commonwealth fully cooperating with this commission, by providing one of its officers to give evidence.”
Walker pointed out that the ABF “has no relevant responsibility” for the passengers being allowed to disembark, but the position wasn’t as clear for Department of Agriculture, Water and the Environment officers, who have the final say on pratique under the Biosecurity Act. He said it was clear that a DAWE Biosecurity Officer could grant pratique for a cruise ship “only on the favourable word” of a NSW Health’s Human Biosecurity Officer, and the sharing of functions to achieve a shared goal was “not too bad”.
“It was the state’s expert panel that made the operative decision, relayed accurately (if by a clumsy means) to the DAWE Biosecurity Officer who granted pratique. That seems by far to be the most likely understanding of what happened, by dint of administrative conduct that undoubtedly could have been more crisp and formal. To repeat, neither the ABF nor any ABF officers played any part in the mishap,” he said.