[russellw]

Originally Posted by Tickford.

edit: If anyone is up for some reading, click HERE for the report, released yesterday. All 320 pages of it!

It's worth reading for those who really want to gain an understanding.

It has an interesting introduction, describing (in a classic piece of understatement) the whole fiasco as a 'mishap'.

The intro further goes on to make this comment about operators of the Ruby Princess:

Princess Cruises or Carnival, as the cruise ship business responsible for the passengers and crew is variously named in the Report, was notoriously the object of considerable blame and criticism in public discussion leading up to, and indeed during, this Commission. For the reasons that are explained in the body of this Report, such issues are not central to the course of conduct that brought about so many infected people departing relatively unrestrained that unfortunate morning
from the ship, into the community – in New South Wales, other parts of Australia, and overseas especially in the United States of America.
But it is not sensibly possible to pass over Carnival’s part in this episode...

Further, about the public health response:

..it must be understood that the shortcomings in the public health response that are found in detail in the body of the Report are by no means to be regarded straightforwardly as causes of the suffering that has followed.

.. and:

As explained in the body of the Report, the proper approach to the COVID-19 threat posed by the Ruby Princess’s nearing the Heads on 18 March 2020 called for the travellers on board to be regarded, in the absence of test results being known, as presenting a real possibility – not remote, not fanciful – that they included one or more infected people who could transmit the virus and perhaps spark an outbreak of infection, if no steps were taken to prevent or limit that outcome.

.. and:

On the whole, the State public health officials did adequately attempt to protect the public health against COVID-19 on cruise ships, by reference in particular to the need to check for human error. However, and it is a big however, their attempts sadly miscarried in this event.

The fact is that the Expert Panel knew, as well as Ms Ressler as a senior epidemiologist knew, that during the voyage the class of possibly suspect cases of COVID-19 had substantially expanded by inclusion of the criterion of any recent presence overseas (such as arrival from the USA for the cruise).

Members of the Expert Panel, not only Ms Ressler, failed to realise and act on this information. Combined, it was a serious mistake that contributed to the relatively unrestrained scattering of passengers on 19 March 2020.

... the failure to await test results on 19 March is a large factor in this Commission’s findings as to the mistakes and misjudgements that caused the scattering of infected passengers. As it happened, two other factors
in relation to testing were also significant, if not so causally important.

First, the avoidable delay in testing and notifying its results could have had real public health consequences – although the hypotheticals are quite beyond confident reconstruction.

Second, the small number of swabs taken on board the Ruby Princess and available for testing early on 19 March represented a woeful shortcoming in the stipulated number.

Somewhat more damningly (after acknowledging that what 'might' have happened is impossible to determine:

What can confidently be concluded is that we – New South Wales and
the broader community – would have been very likely considerably better off with respect to COVID-19 had those mistakes not been made.

Here is the review of the countervailing factors (excuses basically) to see what impact they might have had, including:

Was expense, public or private, a reason not to await results in order to consider eg quarantine arrangements rather than scattering? No – and the massive knock to public and private wealth as a result of every outbreak of COVID-19, including from the Ruby Princess, explains why concern about expense would never have justified a passive response.

Was a disinclination to inconvenience returning passengers, especially our
overseas guests, an explanation for the Expert Panel’s assessment of low risk and not awaiting test results? No, again. Although personal liberty was properly considered, the evidence does not suggest that some misplaced preference for an individual’s freedom from restraint over the community freedom from further infection motivated the course taken.

What about the risk of infection posed to passengers kept on board? Was the then recent experience of a rapidly and widely spread outbreak on the Diamond Princess in Japan a reason that drove a decision to get passengers off the Ruby Princess as soon as possible? It has to be said immediately that members of the Expert Panel did not say so, and the finding is that this fear did not motivate their decision.

The ABF was cleared of any culpability given that the decision (despite their name) was well out of their bailiwick:

Given its lack of medical or epidemiological expertise, it is well for the public good that the ABF (and, for that matter, the Department of Home Affairs) do not bear any responsibility for the Ruby Princess mishap.

The Department of Agriculture, Water & Environment (DAWE) and State Health Dept. didn't fare quite so well:

It was the State’s Expert Panel that made the operative decision, relayed accurately (if by a clumsy means) to the DAWE Biosecurity Officer.

I find the comments in relation to Ministerial responsibility, interesting:

Perhaps those making calls for the Minister to appear at a Commission hearing during the Inquiry had in mind some version of the rather nebulous so-called Westminster theory of ministerial responsibility. This
report is not the place to expatiate on the unsatisfactory nature of this idea, that does not really warrant being called a doctrine. Of course a Minister should resign in some circumstances, but as this Commission sees it, without wading into the partisan politics, this case would not appear to fit that outcome. The failures were professional – failures in decision-making by experts. They are not, as to their expert judgements, subject to Ministerial direction. Nor should they be, unless our system
of government were to become farcical.

Most of the 'serious' errors were by the Expert Panel and the summary of that Chapter reads:

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.

.. but Carnival didn't escape either:

Carnival should have ensured that Dr von Watzdorf was made aware of the change to the CDNA “suspect case” definition on 10 March 2020. 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. Those persons meeting the definition of a suspect case should have been required to isolate in their cabins.

.. or NSW Health

The directive to allow passengers to onward travel interstate and internationally after disembarkation on 19 March did not appropriately contemplate or comply with the terms of the Public Health Order that came into effect on 17 March, which required all cruise ship passengers entering the State from any other country to isolate themselves in suitable accommodation for 14 days.

and further..
The fact sheet linked to an email sent to passengers at 10:46am on 20 March incorrectly advised that they were permitted to continue with onward travel, despite being identified as “close contacts” of a confirmed COVID-19 case. Although this advice was corrected by NSW Health by the evening of 21 March, it was at that stage too late to prevent a considerable number of interstate and international passengers from
onward travelling, including some passengers who were symptomatic during transit.

That's about the key salient points from my reading except to say that, as is normal with these reports, no real culpability is placed on public servants for doing their job:

as noted in this Chapter and throughout the body of this Report. It is accordingly right that I acknowledge as Commissioner that these imperfections in the State’s public health work on 18-19 March 2020 in
relation to the Ruby Princess should not be taken as damning condemnation of the individual public servants involved. The lapses identified are not in some way typical or characteristic of them or their colleagues. Some of these estimable individuals, as the evidence showed, remain in charge of weighty aspects of the State’s frontline response to the pandemic. I have to say that my confidence in their good faith and
skilled diligence in these continuing efforts was not dented by the criticism I have expressed about the Ruby Princess episode. Everyone makes mistakes, and when we judge one another we should bear that in mind.