An official inquiry into the coronavirus outbreak on board the cruise ship ’Ruby Princess’ blamed the New South Wales Government public health agencies for allowing hundreds of COVID-positive passengers to leave the ship.
It broadly exonerated Princess Cruises and the the cruise ship’s Master of any wrongdoing, though it found that Carnival Australia should have provided the ship’s physician with updated guidance on which patients to treat as ‘suspect cases.’
“Our hearts go out to everyone who has been affected, particularly those who lost loved ones,” said Princess in a statement. “The Commission’s report confirms that none of our people – the Master, the ship’s doctor, or members of our shore side port agency team – misled public authorities involved in Ruby Princess being permitted to disembark guests on 19th March.”
When ‘Ruby Princess’ called at Sydney, NSW on 8th March, NSW Ministry of Health assessed her coronavirus status as ‘medium risk’, based on 170 recorded cases of acute respiratory illness (including known flu) on board.
The agency’s inspection team conducted an on board screening upon the ship’s arrival, and 366 people presented themselves for examination. Four were selected for COVID testing based on their symptoms, and none tested positive.
On 15th March, the ’Ruby Princess’ changed course to return to Sydney as a consequence of Australia’s newly-enacted cruising ban. The same day, ship’s physician Dr Ilse von Watzendorf notified NSW Health that it appeared the ship was “in the early phases of an Influenza A outbreak on board.”
Those with symptoms had tested positive for influenza, she advised, indicating that the outbreak was non-COVID-related.
The following day, a passenger went to the ship’s medical centre with a high fever and ‘signs of cardiac strain,’ but he tested negative for influenza. On board COVID testing was not available to determine whether his symptoms were related.
On 17th March, the ship’s log for passengers reporting acute respiratory distress showed a ‘significant spike,’ according to the report. This log was communicated to NSW Health, and the agency used it to evaluate the ship’s suitability to dock and disembark.
However, based on an outdated definition of a suspected COVID case, NSW Health’s risk assessment panel determined that the ship presented a ‘low risk’ for novel coronavirus.
In its after-action analysis, the commission of inquiry concluded that the panel’s low risk assessment ‘was a serious and material error’ leading to uncontrolled release of COVID-positive passengers.
“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,” the commission said in the report.
On 18th March, as the vessel approached Sydney, a ships’ agent with Carnival Australia asked NSW Ambulance for transport for two patients with ‘febrile upper respiratory tract infections.’
NSW Ambulance set a chain of notifications in motion, launching a confused discussion among a plethora of agencies and entities – Port Authority of New South Wales, NSW Health, NSW Ambulance, the Royal Prince Alfred Hospital, the NSW Department of Agriculture, Water and Environment, the Australian Border Force, the local ‘000’ emergency call centre, NSW Police Marine Area Command – along with Carnival Australia and the ’Ruby Princess’ crew.
During this conversation, the port authority suspended the vessel’s pilot appointment and requested further information. After learning from Carnival that the ship was assessed as a ‘low risk’ vessel, port officials rescheduled the pilot service and brought the ship in to berth.
The following morning, NSW Health conducted no health assessments on board, and all passengers disembarked.
That day, 13 COVID test swabs that the ship’s medics had taken while the cruise ship was underway were sent to a lab for testing. The samples were not marked as high priority, as the ship was considered ‘low risk,’ and they were not processed until the night of 19th-20th March. The commission described this delay as ‘inexcusable,’ as it delayed the public health response measures that followed.
NSW Health learned that three of these tests came back positive at 0830 hours on 20th March, and it raised the alarm. Initial efforts to contact and quarantine passengers had limited success, though they did find that nearly 400 passengers had self-reported COVID-19 symptoms.
Ultimately, 21 crew members and 663 Australian passengers tested positive for COVID-19, making the ’Ruby Princess’ voyage one of the nation’s largest single sources of infection.
The government of NSW Premier Gladys Berejiklian has accepted the commission’s findings and admitted its responsibility.
“The lessons weren’t learnt soon enough and again I apologize unreservedly on behalf all of those individuals and agencies who made those mistakes,” said Berejiklian in a statement. “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 [of the lapse].”