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As five separate inquiries examine how the ship became Australia’s largest source of Covid-19 deaths, the messy arrangements at our borders are now under intense scrutiny. By Karen Middleton.

What happened with the Ruby Princess

The Ruby Princess departing Port Kembla on April 23.
Credit: AAP Image / Dean Lewins

As the Ruby Princess sailed towards Sydney Harbour on the night of March 18, phone calls, emails and text messages flew, including between the ship and the shore.

They involved the ship’s captain as well as its doctor, New South Wales Health, the Carnival Cruise Line port operations director and port agent, the NSW Ambulance service, the port authority’s harbourmaster from NSW Vessel Traffic Services, Australian Border Force, the Department of Home Affairs, and the Department of Agriculture, Water and the Environment.

Late into the night, the conversations went back and forth, a web of interactions that reflects the tangle of responsibilities activated when a cruise ship approaches Australia with sick passengers on board.

In the end, under a power delegated by the Commonwealth Medical Officer, issues relating to human health are a state responsibility – it was NSW Health that cleared the ship to dock.

Despite all these exchanges, at least as much as because of them, the Ruby Princess arrived at Sydney’s Overseas Passenger Terminal in the early hours of March 19. Its 2700 passengers disembarked and fanned out across Australia and around the world.

They included 128 people who had reported being sick, 24 of whom had a high temperature and 13 who had been swabbed for Covid-19. The results of those tests were still pending when passengers poured out of the ship over the course of four-and-a-half hours, into public and private transport, and disappeared. Two with other serious conditions were taken directly to hospital by ambulance.

Hundreds more Ruby Princess passengers and crew would eventually be diagnosed with the virus, two of whom would spark an outbreak in north-west Tasmania that temporarily closed the region’s public and private hospital.

The decision to let the passengers disembark into what was supposed to be self-isolation for 14 days, instead of compulsory quarantine, would become the biggest single source of Covid-19-related deaths in Australia to date.

In the weeks since that event, much finger-pointing has ensued over who was actually responsible. This week, the NSW special commission of inquiry into the Ruby Princess began its hearings in earnest, aiming to form a picture of who knew what – or should have – and what was and wasn’t done.

What is emerging reveals some involved – especially NSW Health – took a by-the-book approach to aspects of their responsibilities and a surprisingly unquestioning approach to others.

NSW Police has begun its own criminal investigation alongside a coronial inquiry, and a senate select committee has taken evidence about the Ruby Princess. The Department of Agriculture, Water and the Environment also launched an investigation of its own this week.

The Ruby Princess left Australia on March 8 on a round-trip cruise to New Zealand. It was due to return on March 21 but the global coronavirus pandemic and a new Australian government ban on cruise ships cut the journey short.

The ship had been exempted because it was already at sea when the ban took effect, but it was carrying sick passengers and turned for home two days early, booked to dock early on March 19.

 

This week, the special commission’s key focus was on some of the factors that influenced the NSW Health clearance.

Apparently based on an acute diseases log that the ship’s doctor had provided, a NSW Health assessment panel determined the ship was at low risk of spreading the infection.

That meant health officials would not board to assess the situation when it docked, and passengers would disembark before the Covid-19 test results had been received.

On the night of March 18, that decision was causing some concern.

Even the ship’s doctor, Ilse von Watzdorf, had expected NSW Health officials would board and that passengers would be held until the test results were known. “I was surprised that we were allowed to do that without waiting for the result to come through,” she told the inquiry on the first day of hearings two weeks ago.

Dr von Watzdorf said she expected an on-board assessment because that had happened when the ship completed its previous cruise, covering the same route, less than a fortnight earlier.

When it arrived back in Sydney on March 8 – before turning around and heading out again – the Ruby Princess was also carrying passengers who had been swabbed for the virus. On that occasion, health officials boarded to assess passengers. They swabbed those with possible Covid-19 symptoms and the swabs came back negative.

The ship’s hotel manager, Charles Verwaal, had a similar expectation. “I think we were very surprised that we did not have the same treatment from NSW Public Health as we did on the 8th,” he told the inquiry on April 23.

Counsel assisting the inquiry, Richard Beasley, SC, asked Verwaal whether he was more concerned about the possibility of undiagnosed Covid-19 on the second voyage.

“I would guess so, since we are further down the line,” Verwaal replied.

But something had mitigated his concern. On the second trip, five patients had taken ill and been swabbed and tested for Covid-19 when the ship docked in Wellington. Those tests had come back negative.

“And then NSW [Health] did not come on board to do that pre-clearance so it gives you mixed feelings and you… you think perhaps it could be [risky], but on the other hand the signals you get are that it’s not the case. So it’s very difficult.”

 

Dr von Watzdorf’s main point of contact with the health authorities was Kelly-Anne Ressler, an epidemiologist and state health official who worked in the south-east area health unit responsible for incoming cruise ships. Ressler and von Watzdorf exchanged a series of WhatsApp messages from the day before the ship docked, discussing the health status of passengers on board.

The doctor had also contacted Ressler a few days earlier by email.

“We seem to be in the early phases of an influenza A outbreak on board,” she wrote on the night of March 15.

Two days after that, on the afternoon of March 17, NSW Health asked the doctor for information on the health and travel history of passengers and crew, as required under a protocol it had just adopted in light of the pandemic.

On the morning of March 18, von Watzdorf filed a log with NSW authorities as required. It showed 104 passengers had come to the ship’s medical centre with acute respiratory symptoms. Of those, 36 had a temperature above 38 degrees Celsius, the standard benchmark for a fever. That latter group represented 0.94 per cent of all people on board.

The numbers and percentage are significant. The NSW authorities had set a rate of 1 per cent or more for flu-like symptoms – generally accepted as involving a fever – as the trigger to increase a ship’s risk rating from low to medium.

A medium rating – which was what the ship had been given on its previous voyage, due to the presence of passengers from designated high-risk countries – would have prompted an on-board assessment.

In fact, NSW Health was not following its own written protocol properly. It stipulated that the 1 per cent trigger should have applied to anyone with acute respiratory symptoms – a much bigger group than just those with a fever. Had it correctly applied its protocol, the rate was well over the threshold and should have triggered an on-board assessment.

It’s not clear why that happened. But the mix-up earned Ressler – as an agency representative and a significant adviser, albeit not the ultimate decision-maker – a savaging from commissioner Bret Walker, SC.

“Is there anything you want to tell me as to why I should not draw the conclusion that there has been a reprehensible shortcoming in NSW Health in that regard?” Walker asked.

His questions reduced Ressler to tears. “Commissioner, all I can say is that I’m very sorry it turned out the way it did,” she responded. “It was not our intention. Myself and my colleagues at the public health unit were working very hard on this. We did what we could and if we could do it again, it would be very different.”

The commissioner’s tone earned him a rebuke of his own from Prime Minister Scott Morrison who said Walker should “tone it down”.

 

Kelly-Anne Ressler had been a member of the on-board assessment team after the earlier voyage, and said she was “surprised” at what she found on the ship.

The ship’s doctor had told NSW Health there were 170 who had reported feeling unwell and the ship’s crew was asked to make an announcement before officials boarded, urging anyone feeling unwell to gather in one of the ship’s restaurants for an assessment.

When the officials arrived, there were 360 people jammed in together.

“I remember walking in and saying to somebody, ‘Are all of these people here for assessment?’ ” she told the inquiry. “And they said, ‘Yes.’ ”

Despite this, passengers were still allowed to disembark before the Covid-19 test results were known, because the protocol allowed it. In the wake of what happened on the next voyage, that protocol has been changed.

The Ruby Princess has also highlighted the difference between the customs and immigration treatment of airline passengers and those who take cruises. Passengers who took the round-trip voyage to New Zealand did not have their passports checked on return.

Australian Border Force commissioner Michael Outram told a senate inquiry this week that it had been the practice for 40 years that round-trip cruise passengers to certain designated low-risk countries in the Pacific were not subjected to a passport check on return. But anyone who boarded elsewhere for just the return leg faced the usual checks and ABF officers still boarded the ship to check luggage.

On the night of March 18, the ship’s accelerated return schedule was accelerated further. Carnival’s Sydney-based port agent, Bibi Tokovic, took a call from her boss about 7pm to say the planned 6am docking had been moved forward to 2.30am. She needed to book a pilot for 1am to guide it into the harbour.

Dr von Watzdorf also contacted Tokovic, asking her to book ambulances for two passengers needing urgent medical treatment.

One, Anthony Londero, had a cardiac condition and tests showed he had suffered a mild heart attack. The other, Lesley Bacon, was suffering acute femoral nerve compression and was unable to walk.

The doctor had also told Tokovic both patients had respiratory symptoms, a temperature above 38 degrees Celsius, and had tested negative for influenza.

These were all potential indicators of Covid-19 and both patients had been swabbed for the virus. Von Watzdorf had emphasised that the ambulance crew should wear personal protective equipment, just in case.

Tokovic rang NSW Ambulance. She conveyed the warning about personal protective equipment and this appears to have elevated the focus on the virus.

Somewhere in the chain, someone designated that the patients should be taken to the Royal Prince Alfred Hospital in Sydney’s inner west and not to the closer St Vincent’s Hospital, where they would normally go. RPA had been designated as a Covid-19 treatment centre.

The ambulance service notified the harbourmaster, Cameron Butchart, who was not keen to send a pilot out to board an infected ship.

Late that night, Butchart had a conversation with an officer of the Australian Border Force. Who called whom is a matter of dispute. He had another conversation with an officer from the Department of Home Affairs.

Butchart took no notes and can’t remember who they were.

The senate committee heard this week that the federal agencies were all aware of the situation with the ship in the middle of the night. It was clear they were concerned. But while the ABF has a customs and immigration role, it is not in charge of human biosecurity and had no authority to stop a ship from docking.

At one point, permission to dock – known as pratique – was withdrawn and then reinstated.

The port authority phoned Tokovic just before 11pm but the call went through to her voicemail. She had been on the phone half the evening and had to get up again at 1am to go to Circular Quay to meet the vessel. So she was on her way to bed.

Three hours later, von Watzdorf was woken on the ship by a call from the staff captain. The ship was due to dock in half an hour and the harbourmaster was on the phone wanting to speak to her.

“It was 2 o’clock in the morning,” von Watzdorf told the inquiry on April 22. “I had just woken up. But I seem to recall that they wanted to know about the number of patients that we had declared and that there was some concern about it.”

She roused herself and took the call.

“The impression I got from the conversation was ‘Why are we coming in at 3 o’clock in the morning to disembark these guests?’ ”

The doctor was quietly asking herself the same question. She told him about the patients needing medical treatment. The harbourmaster and his colleagues were aware of the ambulance request.

“I think the words they used were, ‘We were worried that this is a bogus call,’ ” she told the hearing.

Dr von Watzdorf explained the ambulances were due to the patients’ other conditions, not because of suspected Covid-19.

The alarm bells had been ringing in NSW Ambulance and in the harbourmaster’s office, considering NSW Health had cleared the ship to berth, and he had called the bridge for clarification.

The conversation appears to have assured him it was safe.

 

The inquiry has unearthed other mix-ups in the handling of the Ruby Princess’s arrival.

The 13 swabs for Covid-19 were not given top priority for testing at the lab, even though swabs from cruise ships were usually designated urgent.

It took more than 24 hours for the results to come back, showing three of the swabs were positive. They were received on March 20, the day after the ship had docked and the passengers had gone.

Many hundreds more subsequently tested positive to the virus. One of the two ambulance passengers, Lesley Bacon, was among those who did not survive it. She died two days after leaving the ship.

When Kelly-Anne Ressler went to match the names of the 13 swabbed passengers against the ship’s diseases log, she discovered one name was missing.

She contacted von Watzdorf on March 20 to be told that an updated log, prepared on the night of the 18th, had not been filed. It had higher numbers of unwell patients.

“I’ll send it now,” the doctor replied. “Sorry, I forgot. The last one was from the morning. It was so crazy.”

NSW Health had not requested the most up-to-date figures before it made its decision, and it seems nobody thought to do so. Its assessment had been based on figures more than 18 hours old, in an environment where the main concern was a fast-spreading virus.

On top of that, it transpired that the ship had filed three human health reports to the federal Agriculture Department, which also has a biosecurity role, over the course of that day. The last of those, at 7.21pm on March 18, showed 128 passengers had respiratory symptoms and 24 had a temperature, signalling the numbers had changed over the course of the day.

Some federal officials believe that should have been a red flag to NSW. It wasn’t. Whether there was pressure on anyone to let the ship dock may – or may not – become clear through the special commission of inquiry or other investigations.

Having the passengers disembark certainly avoided a repeat of what happened to another ship in the same fleet, the Diamond Princess, which sat dockside in Yokohama, Japan, in February with passengers and crew held on board as infection rates rose and rose and officials tried to work out what to do.

The Australian passengers on that ship were eventually flown home and placed into compulsory quarantine outside Darwin for two weeks.

But that same quarantine was not imposed on the Ruby Princess passengers.

In his formal opening remarks to the commission, counsel assisting, Richard Beasley, said apportioning blame would not be the most important aspect of what the commissioner would do.

Rather, it would be determining the facts: who had what knowledge, who passed it on and received it, and who made decisions.

“This is an inquiry and it is ongoing,” Beasley said. “Not all the facts are yet known; to the extent they are, not every issue related to them is as clear as it could be. By the end of the inquiry, that position will have changed.”

Commissioner Walker is due to report in August.

This article was first published in the print edition of The Saturday Paper on May 9, 2020 as "What happened with the Ruby Princess".

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Karen Middleton is The Saturday Paper’s chief political correspondent.