Background to the Ruby Princess Inquiry
The report into the Ruby Princess cruise ship has identified “serious”, “inexcusable” and “inexplicable” mistakes by NSW Health.
In the weeks that following the authorisation for the Ruby Princess to dock in Sydney, 663 passengers and their contacts tested positive for COVID-19, with 28 people dying. As a result, on 15 April 2020, the Special Commission of Inquiry into the Ruby Princess was established, led by Bret Walker SC. The inquiry was to have regard to the global COVID-19 pandemic and the following voyages of the Ruby Princess;
- The departure from Sydney of the Ruby Princess on 8 March 2020;
- The voyage of the Ruby Princess between 8 March and 19 March 2020;
- The docking and disembarkation of the Ruby Princess at Sydney on 19 March 2020; and
- Subsequent efforts to diagnose and treat, and to contain the community transmission of COVID-19 by, Ruby Princess passengers.
The terms of reference for the Inquiry of the Ruby Princess, this includes;
- The knowledge, decisions and actions of Ruby Princess crew, medical staff and the ship operator, Princess Cruises, concerning cases or potential cases of respiratory infections on the ship;
- The information provided to, communications between, and decisions and actions of Commonwealth and NSW agencies, including the Australian Border Force, the Federal Department of Agriculture, Water and the Environment, NSW Health, the NSW Police Force, NSW Ambulance and the Port Authority of NSW;
- Policies and protocols applied by Princess Cruises and Commonwealth and NSW Government agencies concerning managing suspected or potential COVID-19 cases;
- Communications by Commonwealth and NSW Government agencies to passengers disembarking the Ruby Princess; and
- Any other related matters that the Commissioner considers appropriate.
Summary of the Ruby Princess Report
On 14 August 2020, Commissioner Bret Walker SC handed down his report following the Special Commission of Inquiry into the Ruby Princess.
Walker suggested that it was “unhelpful to make recommendations to experts that in truth amount to no more than ‘do your job’”. 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develop “a better awareness” of their roles, and that the Biosecurity Act should “make explicit a requirement to update superseded human health information”.
Mr Walker also declined to make any recommendations against Carnival Australia and said the Australian Border Force had “no relevant responsibility” and did “not play any part in the mishap”.
Health Minister – Brad Hazzard
Addressing the calls for the New South Wales health minister, Brad Hazzard, to resign, Mr Walker states that these were “farcical” (absurd). The report found that NSW Health made “serious” mistakes, but “it should not be thought though that, by some misguided reflex, recommendations should follow”.
Whilst there have been 28 deaths and at least 854 passengers and crew who have contracted the virus due to the cluster linked to the Ruby Princes, Mr Walker concluded that there were “no systemic failures to address”.
NSW Health Public Health Physicians
Commenting on the conduct of the NSW Health public health physicians, Mr Walker states that “The mistakes…were not made here because they failed to treat the threat of Covid-19 seriously,” rather “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.”
NSW Health Expert Panel
The final found that the NSW Health’s expert panel committed multiple “serious” errors in handling the Ruby Princess. 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.
The report uncovered that the ship’s log of acute respiratory diseases, (used to track 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.
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…It was a serious mistake.”
Dr Ilse von Watzdorf: Ruby Princess Treating Doctor
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.
It was described as 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.
Walker also said von Watzdorf “should have notified NSW Health” earlier about the rise in an ill patient 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 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 also emphases that there was “no criticism” made of von Watzdorf and the fact that the Ruby Princess left Sydney with fewer Covid-19 swabs than it should have had.
Australian Border Force
The final report cleared the Australian Border Force, the home affairs department and Hazzard of any responsibility, with Mr Walker finding that some media reports regarding the ABF had been “incorrect”.
This was made regarding the reporting of Andrew Probyn who commented in July that “Ruby Princess passengers [were] allowed off the ship after border force mistook negative flu tests for coronavirus results”.
In response to these claims Walker stated: “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.”
The full report can be found online at this link.