A report by the special commission of inquiry into the Ruby Princess debacle recommends law changes to avoid a future catastrophe.

It also calls for improved co-ordination between a number of bodies, including the NSW Human Biosecurity Officers, the Commonwealth Department of Healthand NSW Health. This includes better understanding each agencys roles, and developing more formal protocols for their interaction and communication.
The report describes the nation’s single-biggest cluster of COVID-19 infections as a “sorry episode”.
As of mid-May, the COVID-19 death toll from passengers aboard the Ruby Princess cruise had reached 22, while 712 passengers and 202 crew have tested positive.
The report describes the nation’s single-biggest cluster of COVID-19 infections as a “sorry episode” that could have been avoided if NSW Health had not failed to await test results of swabs from passengers that were taken off the ship for testing from around 3am.
Instead, Ruby Princess was given the green light to begin disembarking its guests after daybreak on March 19.
All passengers on board the Ruby Princess should have been tested for COVID-19, and disembarkation should not have occurred until the test results were in, says the report. Kate Geraghty
This single act comprised a “large factor in this commissions findings as to the mistakes and misjudgments that caused the scattering of infected passengers”, the report says.
Within hours of passengers being let loose to find their own way home including taking Ubers, taxis, buses, trains and flights three swabs taken from those on board Ruby Princess had come back as positive for COVID-19.
NSW Health also should have “ensured that cruise ships were aware of the change to the definition of a suspect case for COVID-19 made on March 10 by the Communicable Diseases Network Australia (CDNA),” the report says.
Under this upgraded definition, at least 120 people on board Ruby Princess would have met the criteria by March 19.
“The decision [by NSW Health] to assess the risk as low risk meaning, in effect, do nothing is as inexplicable as it is unjustifiable. It was a serious mistake,” Mr Walker says.
The decision [by NSW Health] to assess the risk as low risk meaning, in effect, do nothing is as inexplicable as it is unjustifiable. It was a serious mistake, Mr Walker says.
Princess Ruby is operated by Princess Cruises, which is owned by the American Carnival Corporation.
Mr Walker reserved some criticism for the parent company, saying Carnival should have ensured their on-board doctor, Dr Ilse von Watzdorf, was also made aware of the change to the CDNA suspect case definition.
“They should also have ensured that passengers and crew aboard the Ruby Princess were informed that there were suspect cases of COVID-19 on board,” it says, adding “those persons meeting the definition of a suspect case should have been required to isolate in their cabins.”
Given that by mid-March, after the Dawn Princess experience, anyone on a cruise ship was considered “to be close contacts” of even one case on board, the “logical and precautionary assumption should at least have justified the public health authorities taking steps to prevent passengers [and crew as well] from scattering into the community after disembarkation,” Mr Walker writes.
The Australian Border Force was also singled out for initially advising passengers during the cruise that their 14-day period of self-isolation would commence from the date of departure from the last overseas port visited by the Ruby Princess, which was Napier on March 15.
This statement was later clarified during the disembarkation process on March 19.
However, yet another disturbing error occurred when authorities allowed passengers to take onward travel arrangements both interstate and internationally, which effectively breached the Public Health Order that came into effect on March 17, requiring all cruise ship passengers entering the State from any other country to isolate themselves in suitable accommodation for 14 days.
“Under the terms of the Public Health Order, the state government should have arranged suitable accommodation for all passengers who were not residents of the State,” the report says, adding some passengers were symptomatic during transit.
Mr Walker points out the disaster continues to play out, given the “human consequences of the scattering upon disembarkation have not yet played out”.