Report: Officials Let Ruby Princess Disembark in "Inexplicable" Error

A special commission of inquiry into the coronavirus outbreak aboard the cruise ship Ruby Princess has completed its investigation, and it has determined that the public health agencies of the government of New South Wales bear primary responsibility for allowing hundreds of COVID-positive passengers to disembark the ship and travel onwards. It broadly exonerated Princess Cruises and the captain of the Ruby Princess of 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 Captain, 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 March 19."

When the Ruby Princess called at Sydney on March 8, 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 onboard 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 March 15, the Ruby Princess altered course and made way 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 onboard.” Those with symptoms had tested positive for influenza, she advised, indicating that the outbreak was non-COVID-related. 

The following day, passenger Anthony Londero checked in to the ship's medical center with a high fever and "signs of cardiac strain," and he tested negative for influenza. Onboard COVID testing was not available to determine whether his symptoms were related. 

On March 17, the ship's log for passengers reporting acute respiratory distress showed a "significant spike," according to the commission. This log was properly 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 However, based on an outdated definition of a suspected COVID case, NSW Health's risk assessment panel determined that the ship presented a "low risk" for novel coronavirus.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 wrote. 

On March 18, 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 panoply 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 center, NSW Police Marine Area Command - along with Carnival Australia and the Ruby Princess' crew. During this extended 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 under way 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 March 19-20. 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 March 20, and it sounded 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 crewmembers and 663 Australian passengers tested positive for COVID-19, making the Ruby Princess voyage one of the nation's largest single sources of infection. 62 secondary and tertiary infections in Australia have been linked back to Ruby Princess passengers. 28 individuals ultimately died, including eight foreign nationals, and the true number of overseas passengers who caught the illness on board is not known. 

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 Monday. “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]."