Ruby Princess Inquiry Findings – Serious Mistakes by NSW Health
Published on August 19, 2020
After three weeks of hearings, the Report of the Special Commission of Inquiry[1] into the Ruby Princess fiasco was delivered on Friday 14 August 2020.
Bret Walker, SC, who led the Inquiry, handed a scathing report with wide criticisms of NSW Health. The Department’s mistakes were labelled serious, inexcusable and inexplicable with the failures coming from decisions made by medical experts.
The report noted that on March 10 this year, the Communicable Diseases Network of Australia amended its guidelines such that everyone on board the ship with symptoms that fit within the newly-defined “suspect case” should have been tested. However, when a risk assessment was conducted on March 18, those that were making the decisions did not have the updated definition of a “suspect case”.
This mistake, according to the Commission “was a serious and material error”. Had the Ruby Princess been notified of the change by NSW Health, “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”.
“NSW Health should also have ensured that such persons were isolated in cabins. These were serious mistakes by NSW Health.” The report also warned that the failure to ensure swabs were collected by an on-board health assessment team “was a serious failure by NSW Health”. Mr Walker describes the delay in obtaining test results for the swabs taken from the Ruby Princess on the morning of March 19 as “inexcusable” and that the “swabs should have been tested immediately.” [2]
Instead, some 2,650 passengers who were deemed ‘low risk’ by health officials were allowed to disembark when the ship docked in Sydney and the Ruby Princess was ultimately linked to at least 900 infections and 28 deaths. “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,” the report stated.
While many people did the right thing when they disembarked, self-isolating at home as recommended, the NSW Government allowed other passengers to travel interstate and abroad, breaching the state’s public health order that came into effect two days earlier with the report nothing that “the directive to allow passengers to onward travel interstate and internationally after disembarkation on March 19 did not appropriately contemplate or comply with the terms of the Public Health Order that came into effect on March 17.” By the time NSW Health corrected the advice on March 21, the inquiry said it was “too late” as many passengers – including some symptomatic ones – were already in transit. “Ultimately, every passenger and crew member of the Ruby Princess should have been tested for COVID-19 while in enforced quarantine,” the inquiry said. “Those who tested negative could then have been released, at appropriate times.”
In response to the Report, NSW Premier Gladys Berejiklian apologised, saying:
“I can’t imagine what it would be like having a loved one or being someone yourself who continues to suffer and experience trauma as a result…I want to apologise unreservedly to anybody who is continuing to suffer, or has suffered unimaginable loss because of mistakes that were made within our health agencies.”
The Premier went on to say “I say not only have lessons been learnt, but clearly those circumstances should and will never happen again in New South Wales.”[3]
The Report did not find any systemic failures and said that “the mistakes made by NSW Health public health physicians were not made here because they failed to treat the threat of COVID-19 seriously…they were not made because they were disorganised, or did not have proper processes in place to develop a plan to assess the risks posed by this disease, and how to limit those risks…those physicians relied on the best science, not pseudo-science or matters of political convenience. They were diligent, and properly organised…put simply, despite the best efforts of all, some serious mistakes were made.” What the Report makes clear is that due to these mistakes, COVID-19 was allowed off the cruise ship and into our community, infecting people across Australia.
Separate NSW Police and coronial inquiries into the Ruby Princess remain ongoing, with findings not expected for some time yet.
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