The report found the panel was “not helped by the drafting of the risk assessment form, which was not updated with the new ‘suspect case’ definition.
“This too was a serious error,” the report states.
The full panel should also have read the ship’s log of the illnesses onboard and, having done so, they should have noticed the “significant spike” in respiratory or flu-like illnesses, particularly on March 17.
“They should have requested an updated log either late on 18 March, or early on 19 March. These are all serious errors.”
The special commission of inquiry into the handling of the Ruby Princess outbreak commissioned by the NSW government has found several “serious errors” were made, leading to an "inexplicable" and "unjustifiable" decision to deem the ship low risk.
The inquiry report, handed to the NSW government on Friday afternoon, found NSW Health’s expert panel made a “serious and material error” when it conducted its risk assessment of the Ruby Princess on March 18 - a day before it docked in Sydney with COVID-19 positive passengers on board, who were allowed to disembark.
The panel had deemed the ship “low risk” because members did not have updated CDNA guidelines from March 10 in mind, the report states. These updated guidelines meant all on board the ship who had an acute respiratory illness or influenza-like illness were suspect cases for COVID-19 and "all should have been tested".
Commissioner Bret Walker said in his report the decision to assess the ship as low risk meant, “in effect, ‘do nothing’,” and that it “is as inexplicable as it is unjustifiable”.