Ruby Princess inquiry: NSW Health made ‘serious mistake’ when assessing travel history of passengers

New South Wales Health made a “serious mistake” in using an out-of-date arrival form template for the Ruby Princess when it docked in Sydney, the special inquiry into the cruise ship that resulted in a Covid-19 cluster has heard.

Commissioner Bret Walker SC on Wednesday heard the first of two days of closing submissions that come after more than a dozen days of hearings since April.

The counsel assisting the inquiry, Richard Beasley SC, argued the NSW Health policy of grading ships as low, medium and high risk were “meaningless” and “a distraction”.

Related: Ruby Princess doctor took swab and 'cleared' passenger who later tested positive for Covid-19, inquiry told

He told the inquiry permission for the ship to dock on 19 March should not have been granted before Covid-19 swabs taken on board had been tested and returned results.

Beasley also argued a NSW Health team should have boarded and tested everyone with symptoms.

The inquiry heard there was “a very large noncompliance” with procedures because only 10 Covid-19 swabs were taken from sick passengers during the ship’s final leg to Sydney.

Beasley said NSW Health made a “group mistake” in not fully updating an arrival form handed out on 18 March. The form asked passengers to report if they had been in “mainland China, Italy, Iran, South Korea, Cambodia” and other then-Covid-19 hotspot countries in the past 14 days.

However, by that date, the policy had changed to include all international travel, but this was not reflected on the arrival card.

The Ruby Princess was classified low-risk when it docked on 19 March because it had only travelled between New Zealand and Australia – but passengers had flown in from the US and UK prior to boarding.

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“[That form] was a question prone to mislead and distract the [NSW Health assessment] panel,” Beasley said. “It is conceded, it is described as a mistake or oversight.”

Witnesses had previously told the inquiry they would have altered their risk assessment from low to “at least” medium if that form had been changed. “I would describe that as a serious mistake,” the counsel assisting said.

He also told the inquiry the risk gradings of low, medium and high were “meaningless” and a “distraction”, because health authorities should have focused on what precautions to take, and the potential “catastrophic” impacts of a novel disease that could spread through the community.

Beasley described the lack of swabs taken as “a very large noncompliance” with procedures.

However, he did not recommend making adverse findings against either NSW Health or the Ruby Princess’s operator, Carnival Australia, saying there were logistical issues with sourcing swabs.

“There is evidence of email exchanges between [the ship’s senior doctor] Dr Ilse von Watzdorf and [NSW Health senior epidemiologist Kelly-Anne] Ressler, about difficulties Von Watzdorf was having in sourcing a sufficient number of swabs,” he said.

“Ms Ressler provided Dr Von Watzdorf with about 25 swabs but Von Watzdorf was told bv Ms Ressler to make sure she has enough swabs. The evidence is Von Watzdorf was attempting to source swabs.

“This was not ignored by NSW Health, was not ignored by Princess or Carnival or Dr Von Watzdorf.”

However, Walker noted: “I think there is room for criticism that such a large enterprise was not able in a timely fashion to meet a global emergency with basic supplies.”

The inquiry had also previously heard the Covid-19 swabs taken off the ship were delayed for at least 16 hours because lab technicians forgot to process them as a priority.

Swabs were taken off the ship at 3am on 19 March and immediately driven to a lab.

Usually, any swabs that arrived by 10am would return results by 4pm, Beasley told the inquiry previously.

But when a NSW Health employee called at 4pm they were told the swabs had not yet been processed. Results were finally returned at 8am on 20 March.

Beasley on Wednesday said this was “unreasonable” and the swabs “should have been tested immediately”.

“I know that might have meant an early morning for someone in a lab, but in a pandemic that might be part of the job.”

Beasley told the inquiry NSW Health should have tested all passengers and kept them confined to their cabins until the first positive test was returned.

Then passengers should have been taken off the ship, safely quarantined and given medical treatment.

Related: NSW government relies on promises from hotels despite Covid-19 risks of large venues

The inquiry also heard a NSW Health media director attempted to edit a NSW Health report – but this was rejected by senior doctors.

Beasley said a report received input from a media director who he and Walker agreed was unqualified from a health perspective.

“A report like this should never go to someone who is called a director of media,” Beasley said.

“It did go to him for his input. He made some suggested changes. [But] to his credit, Dr [Jeremy] McAnulty flicked them all out.”

Walker is required to report to the NSW premier and the NSW governor by 14 August. The inquiry continues.