Ruby Princess inquiry finds NSW Health made 'serious' errors allowing cruise to disembark

The Ruby Princess inquiry has declined to make any recommendations against NSW Health, despite finding it made multiple “serious”, “inexplicable” and “basic” errors when allowing the cruise ship to disembark in Sydney in March.

Commissioner Bret Walker SC argued in his final report, released on Friday, that it was “unhelpful to make recommendations to experts that in truth amount to no more than ‘do your job’”.

Walker also declined to make any recommendations against the cruise ship’s operator, Carnival Australia, and said the Australian Border Force had “no relevant responsibility” and did “not play any part in the mishap”.

The commissioner said calls for the New South Wales health minister, Brad Hazzard, to resign were based on a “farcical” idea of government.

After more than 20 days of hearings and evidence, the report found that NSW Health made “serious” mistakes, but “it should not be thought though that, by some misguided reflex, recommendations should follow”.

So far, the Covid-19 cluster linked to the Ruby Princess has resulted in 28 deaths, while at least 854 passengers and crew contracted the virus. But Walker wrote that there were “no systemic failures to address”.

Related: Coalition denies covering up border force role in letting Ruby Princess passengers go

“The mistakes made by NSW Health public health physicians were not made here because they failed to treat the threat of Covid-19 seriously,” he said.

“They were not made because they were disorganised, or did not have proper processes in place. Put simply, despite the best efforts of all, some serious mistakes were made.”

The only recommendations in the report were that the NSW human biosecurity officer guidelines “should be reconsidered” when it comes to granting pratique (the approval of a ship to dock), that various government departments develop “a better awareness” of their roles, and that the Biosecurity Act should “make explicit a requirement to update superseded human health information”.

The final report did find NSW Health’s expert panel committed multiple “serious” errors in handling the Ruby Princess and effectively “did nothing”.

The ship’s log of acute respiratory diseases, which tracked how many passengers were ill, was not read by all members of the expert panel. They should have noticed the “significant spike” in respiratory illness, the report said.

Walker found the expert panel did not pay enough attention to a new guideline, issued by the Communicable Diseases Network of Australia on 10 March, which meant that all passengers on board with flu symptoms should have been tested, and treated as suspected Covid-19 cases.

Instead, the ship was classified as “low risk” on 18 March because it had only been between New Zealand and Australia, and not to any then hotspot countries. However, many passengers had come from overseas, and dozens had become sick on board.

“In light of all the information the 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 found. “It was a serious mistake.”

The inquiry heard NSW Health was relying on an out-of-date log of respiratory diseases when it made the initial assessment of the ship. The ship’s senior doctor, Dr Ilse von Watzdorf, did not send through an updated log of illness until after the ship had already docked. This showed a rise in the number of ill patients.

Walker said it was a “serious error” that NSW did not request an updated log either late on 18 March or early on 19 March when the Ruby Princess docked.

He also said von Watzdorf “should have notified NSW Health” earlier, but this was an honest oversight.

“This is an oversight by Dr von Watzdorf. It should be emphasised as such, but no more. It was not something that was deliberate or calculated. It was not something she was asked or required to do under the enhanced procedures.

“Given the lengthy hours she was working, and the pressure she was no doubt under in the final stages of the cruise, it is understandable why it did not enter Dr von Watzdorf’s mind to inform NSW Health about the additional persons who had been diagnosed.”

Walker said it was “unclear whether any different decision would have been made” if she had sent the log earlier.

Walker also said “no criticism” was made of von Watzdorf and the fact that the Ruby Princess left Sydney with fewer Covid-19 swabs than it should have had.

He said there should be no criticism of another Carnival employee, Peter Little.

“No criticism is made of Mr Little for not informing NSW Health of what he perceived as the ‘significant spike’ in [acute respiratory illness/influenza-like illness] numbers on the Ruby Princess on 17 March.”

No recommendations were made regarding the cruise ship operator’s conduct.

The report also cleared the Australian Border Force, the home affairs department and Hazzard of any responsibility, with Walker writing that some media reports regarding the ABF had been “incorrect”.

The ABC’s Andrew Probyn reported in July that “Ruby Princess passengers [were] allowed off ship after border force mistook negative flu tests for coronavirus results”.

In his report, Walker wrote: “As this report was being finished, some interesting journalism was published that advanced the notion that a basic misreading by an ABF officer of negative influenza results as meaning negative Covid-19 results, had somehow contributed to the decision to let the passengers go as they did on 19 March. As the body of the Report spells out, that is not correct.”

He concluded that “the relevant legislative provisions make it crystal clear that the Australian Border Force, despite its portentous title, has no relevant responsibility for the processes by which … passengers were permitted to disembark from the Ruby Princess”.

“The ABF (and, for that matter, the Department of Home Affairs) do not bear any responsibility for the Ruby Princess mishap.”

But responding to Walker’s findings on Friday, Labor senator Kristina Keneally sought to push the blame back onto the federal government, accusing the prime minister, Scott Morrison, of having “lied” when he said during a March press conference that cruise ships would be “directly under the command of the Australian Border Force”.

“If the Ruby Princess was ‘directly under the command of the Australian Border Force’, then why didn’t the ABF stop passengers disembarking the Ruby Princess on 19 March?” she said in a statement.

“What this proves is that when Scott Morrison said ‘directly under the command of the Australian Border Force’ he lied.”

Keneally said ABF and agriculture department officials were on board the ship on 19 March so “why didn’t the prime minister give them powers to stop passengers disembarking?”

Walker in his report responded to calls from some politicians that Hazzard should have appeared as a witness before the commission – or resigned.

He describes this as a “farcical” understanding of the minister’s role.

“This commission saw no aspect of ministerial conduct that amounted to any action or inaction of any relevance to be investigated in this Inquiry – let alone by calling the minister as a witness,” he wrote.

“Of course a minister should resign in some circumstances, but as this Commission sees it, without wading into the partisan politics, this case would not appear to fit that outcome. The failures were professional – failures in decision-making by experts. They are not, as to their expert judgments, subject to ministerial direction. Nor should they be, unless our system of government were to become farcical.”

Walker did, however, criticise the federal government for resisting attempts to call witnesses from the commonwealth, describing it as “the one fly in the ointment”.

“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,” the report said. “Quite how this met the prime minister’s early assurance of full co-operation with the commission escapes me. This waste of time and resources, when time, in particular, was always pressing, was most regrettable.”

Related: Ruby Princess inquiry: how distractions and mistakes led to a ‘catastrophic’ Covid-19 cluster

The inquiry heard from passenger Paul Reid, who said a male doctor on board took a swab from his nose and throat, dipped it “in a mixture”, then told him “you don’t have coronavirus, you have the common cold”, despite the ship having no Covid-19 testing facility on board. Reid later tested positive for Covid-19.

Passenger Josephine Roope, whose friend died of Covid-19, also said the ship’s medical staff told her three times that her friend “only [had] the flu”, even though she had tested negative for influenza.

No recommendations were made regarding these matters in Friday’s report.

The report found passengers were given incorrect advice, multiple times, about how long they should isolate.

It found that passengers were “incorrectly advised by the ABF” during the cruise about the length of their self-isolation, and a fact sheet from NSW Health on 20 March “incorrectly advised that they were permitted to continue with onward travel”.

“The state government should have arranged suitable accommodation for all passengers who were not residents of the State,” the report found.

“Although this advice was corrected by NSW Health by the evening of 21 March, it was at that stage too late to prevent a considerable number of interstate and international passengers from onward travelling, including some passengers who were symptomatic during transit.”