In the report, the federal government was also sharply criticised for refusing to allow an official to appear before the inquiry, with commissioner Bret Walker SC saying this contradicted Prime Minister Scott Morrison’s promise of full cooperation.

The Premier has said that all of the recommendations will be implemented and that the NSW government will work with federal agencies involved to strengthen protocols.

“Can I now apologise unreservedly to anyone who suffered as a result of the mistakes outlined in the report… as a result of individuals in the health department or the health agency,” Ms Berejiklian said.

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Ms Berejiklian added that lessons had been learned, but said the tragedy “should and never will happen again in NSW”.

The Premier stressed that Mr Walker’s report found there weren’t systemic issues and had there been, she would have taken action.

“He has full confidence in those agencies continuing to work on the pandemic and I think we can say, since that time we have learnt a lot,” she said.

The inquiry was established in April after thousands of passengers were allowed to leave the cruise liner at the conclusion of two separate voyages in March.

In the weeks that followed, 663 passengers tested positive to COVID-19 in Australia and overseas and 28 people died.

NSW Police commissioner Mick Fuller said that a criminal investigation into what happened is still underway.

NSW Health Minister Brad Hazzard also apologised for the government’s failing.

When asked if he would take ministerial responsibility for those mistakes, Mr Hazzard said he would “rely on Bret Walker’s commentary”.

“There are learnings [everyday] by NSW Health, and those learnings have continue to enable us to get to where we are today, which is… a positive position.”

A ‘scathing report’ across the board

The inquiry, led by the eminent barrister, was established on 15 April and held hearings across 21 days. 

Mr Walker found serious mistakes and misjudgements on the part of health officials. 

He said that in light of all the information the NSW health expert panel had, “the decision to assess the risk of the Ruby Princess as ‘low risk’ – meaning, in effect, ‘do nothing’ – is as inexplicable as it is unjustifiable. 

“It was a serious mistake,” he wrote.

“The mistakes made by NSW Health public health physicians were not made here because they failed to treat the threat of [COVID-19] seriously.

“They were not made because they were disorganised, or did not have proper processes in place. Put simply, despite the best efforts of all, some serious mistakes were made.”

As a result, the report outlined 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.

Recommendations included changing NSW human biosecurity officer legal guidelines when it comes to granting pratique (the approval of a ship to dock), that various government departments develop “a better awareness” of their roles.

Mr Walker said the Biosecurity Act “should mandate a requirement to update superseded human health information.”

There had also been speculation about whether the Australian Border Force had any responsibility for the disaster, but Mr Walker stressed “neither the ABF nor any ABF officers played any part in the mishap”.

“The relevant legislative provisions make it crystal clear that the Australian Border Force (ABF), despite its portentous title, has no relevant responsibility for the processes by which, by reference to health risks to the Australian community, passengers were permitted to disembark,” he said.

The commissioner took aim at the Commonwealth after lawyers for the federal government threatened to launch High Court action to force the Ruby Princess inquiry to withdraw a summons for a departmental worker who refused to testify.

Mr Walker was blunt about the federal government’s attitude to the inquiry and previously stated “the rule of law is not so simply sidestepped.”

“The one fly in the ointment so far as assistance to this commission goes, is the stance of the Commonwealth,” he wrote.

“A summons to a Commonwealth officer to attend and give evidence about the grant of pratique for the Ruby Princess was met with steps towards proceedings in the High Court of Australia.

“Quite how this met the [Prime Minister’s] early assurance of full cooperation with the commission escapes me.

“This waste of time and resources, when time, in particular, was always pressing, was most regrettable.”

Mr Walker stated it seemed a “practical approach was swamped by a determination never to concede, apparently on constitutional grounds, the power of a [State Parliament] to compel evidence to be provided to a state executive inquiry (such as a royal commission or a special commission of inquiry) by the Commonwealth or any of its officers, agencies or authorities.”