August 2020


Storm in a port: The unfolding disaster of the Ruby Princess

By Malcolm Knox
Image of Samantha Brett of 7 News reporting on the ‘Ruby Princess’

© Ryan Pierse / Getty Images

The system breakdowns onboard and onshore that led to the docking of the coronavirus cruise ship

For two hours either side of midnight on March 18, Cameron Butchart was the man who stopped the Ruby Princess from docking in Sydney. The subsequent hundreds of coronavirus cases and deaths, the transmission of disease from Tasmania to Texas, the finger-pointing between government agencies, the reputational damage to a multinational cruise ship company, the judicial and police investigations – all could have remained on the other side of a sliding door if Butchart’s decision stood.

Butchart was the duty harbourmaster, working at the end of a 17-hour day in which he had managed 27 incoming ships, a record number rushing back to beat the imminent closure of Australia’s ports. Among them were four liners from the world’s largest cruise companies: Royal Caribbean’s Celebrity Solstice and Silver Whisper; and the Sun Princess and Ruby Princess, belonging to Princess Cruises, a subsidiary of Carnival Corporation.

Ships arriving in Sydney Harbour are not steered in by their own captains. Pilots are sent out in cutter boats to meet them 3 nautical miles outside the heads. The pilot climbs a rope ladder to the ship, and, on the Ruby Princess, would take a lift to the 10th-floor bridge and assume control of the 113,000-tonne liner.

The port authority’s pilots were no-nonsense men. Sam Chell, who would guide the Ruby Princess through the harbour to its berth at Circular Quay, is an elite big-wave surfer. Tough as they were, the pilots were concerned enough about the coronavirus outbreak to have reservations about boarding cruise ships. Several didn’t think much of the Ruby Princess, having suspected its captain of lying to them about coronavirus-carrying passengers on its previous visit.

At 11pm that night, Butchart, acting on information he had received that the Ruby Princess was a “corona ship”, decided not to send a pilot. Following a chain of logarithmically multiplying screw-ups, Butchart’s decision was itself based on a misunderstanding – yet another erratum in a list of errata that would involve suspected hoaxes, police trying frantically to wake sleeping cruise company employees, and a tragicomic Keystone Kops sequence of mix-ups between state and Commonwealth agencies. Had it been allowed to stand, the Butchart “error” could have saved Australia from its biggest single source of coronavirus infection.

It didn’t. Butchart was “corrected” by a Carnival executive woken from his sleep and speaking from his kitchen. At 12.49am on March 19, Butchart sent Chell to bring the ship in. Butchart, the man who could have stopped the Ruby Princess, told a colleague before he went to bed, “Yeah, well, this could be front-page news in the morning.”

How did it come to this? In the wake of the Ruby Princess fiasco – which would ultimately result in more than 600 confirmed cases and at least 21 deaths across several states and countries – the New South Wales government asked Bret Walker SC to run an independent inquiry to report on how the system overseeing cruise ship arrivals had reached this point. Walker was not assigned to find a scapegoat, but the intrigue was always going to be who knew what when, and who let the ship’s 2670 passengers disembark and scatter with such effect.

To unscramble the egg, we have to go back to two points that created the preconditions for a “corona ship” getting into Sydney Harbour on the say-so of a cruise executive.

As with so many problems in New South Wales, its origin can be traced to Eddie Obeid.

On the disgraced politician’s long rap sheet is a prison sentence for corruptly influencing a bureaucrat at the NSW maritime authority to favour cafe leases at Circular Quay in which Obeid held an interest. Where the maritime authority had previously been a large entity with a single line of responsibility, post Obeid its functions were filleted: waterfront leases were taken over by the state property department, the Port Authority of NSW managed shipping, and supervision of biosecurity for the booming industry of incoming cruise ships was spread between state and federal agencies. Formal admission to ships, or “pratique”, was granted by the federal department of agriculture. Pilotage was the remit of the port authority. Immigration fell to Australian Border Force. Passengers’ health was assessed by NSW Health based on information from the cruise ship companies. This alphabet soup of divided responsibilities evolved in a decade when the number of cruise passengers coming into Sydney annually rose from 40,000 to more than one million. The mishmash of agencies, post Obeid, created the preconditions for the mayhem of March 18, 2020. 

NSW Health was not unprepared for coronavirus on cruise ships. As early as January 21, 2020, nine days before the World Health Organization declared the Wuhan outbreak a public health emergency, 14 days before the virus-riddled Diamond Princess went into quarantine in Yokohama, Japan, NSW Health formed an “expert assessment panel” to respond to COVID-19 on international shipping arrivals. It was convened by Dr Sean Tobin, a medical epidemiologist working with the department’s communicable diseases branch, who, like the other panel members, had no previous experience with cruise ships. In a hastily put together system, Tobin also held the federal role of chief biosecurity officer, with responsibility for granting pratique to incoming ships, based on the NSW Health assessment panel’s advice. If this looks strange, it was: under questioning during the Walker inquiry, Tobin agreed that he was providing health advice about ships to himself and the formal differentiation of his state and federal roles never entered his head.

The panel’s guiding intellect was Professor Mark Ferson, a paediatrician and head of the public health unit for the South Eastern Sydney Local Health District. Ferson, Tobin and their team – comprising Ferson’s deputy Dr Vicky Sheppeard, the director of the Sydney Local Health District Dr Leena Gupta, and Dr Bradley Forssman from the Nepean Blue Mountains Local Health District – reported to the state’s director of health protection, Dr Jeremy McAnulty.

In the early days of the pandemic, NSW Health was quick to respond. On February 12, when Australia still had no COVID deaths and only 27 Wuhan-origin cases, McAnulty and the panel began drafting procedures for assessing the risk of incoming cruise ships. By then, the Diamond Princess, the same tonnage as the Ruby Princess, was berthed in Yokohama with 64 confirmed cases, which would surge to 218 in days. The Diamond Princess posed an appalling dilemma: let the passengers disembark to spread the infection in the community on their way to self-isolation at home, or leave them on board to spread it among themselves? NSW Health wanted to avoid the choice. A third option – compulsory quarantine in hotels – would not be mandated until after the Ruby Princess.

During one February week, McAnulty, his deputy Christine Selvey and the expert panel put together NSW’s guidelines. Three levels of risk were proposed, depending on the spread of symptoms and travellers’ previous presence in certain countries (at that point only China, but soon also Iran and South Korea, then a small group of South-East Asian countries, and eventually the whole world). In an early draft of the guidelines, NSW Health would send an environmental health officer and a nurse, as a minimum, to screen each ship before letting passengers off.

Ferson made a well-intentioned but fateful contribution to the drafting process, emailing: “The down side of having a team meet each boat (apart from the cost and wear on staff) is that if a passenger is diagnosed incidentally after disembarking, we will be asked why we missed a case and it will look worse for everyone.”

Questioned by the Walker inquiry, Ferson would admit that his email was “stupidly written”, yet a day after that first email he doubled down, emailing McAnulty that to test symptomatic passengers “without travel history [to China etc.] is very much overkill”.

McAnulty responded that the department was “trying to balance the very low risk with the very big problem if we have a case on a ship”.

His words were prescient. The Ruby Princess would provide exactly that: a low risk, but a very big problem.

Throughout the process of forming the guidelines, Ferson was the voice of compassion: humane, intelligent and considerate of the variables behind every decision. His approach accounted for the complexity of people’s needs. Fellow panel member Leena Gupta pushed back, advocating a more conservative response. Three hours after McAnulty’s “very big problem” email, Gupta replied with a list of cautious measures, including “strongly recommend[ing]” that no disembarkation take place until results of COVID swabs taken on board had been confirmed onshore. Hunter area public health physician David Durrheim agreed, emailing the panel, “This is a very high risk transmission opportunity. People may fly in from Asia to board in Sydney [or] Newcastle, and travel home on the ship. The burden that cruise ships have placed on Public Health surveillance in the previous pandemic … was enormous … Given the Japanese experience, it appears that this virus spreads efficiently in this petri dish environment. Once the horse (should that be the pangolin) has bolted off the vessel, we have lost control …”

Gupta continued to sound warnings, emailing Ferson on February 14 that “it might be prudent for any respiratory outbreak involving 2 or more persons who are not in the same travelling party … is tested for novel coronavirus prior to arrival at Port. Perhaps this has been considered in the updated [Standard Operating Procedures], but we haven’t seen it.”

Ferson responded: “as i am concerned about the mental health of my staff, i will say that we are unlikely to be able to resource this constantly for the next week or two without completely burning out”.

Gupta kept pressing. “Better to be clear that no one has coronavirus before leaving,” she wrote.

If much of the commentary after the Ruby Princess incident was an exercise in wisdom after the event, Gupta and Durrheim were the exceptions: they saw the disaster before it happened. But their views were set to one side. Neither Tobin, Ferson nor McAnulty could recall any discussion about Gupta’s Cassandra-like warnings. 

By February 19 – when the Diamond Princess had more than 600 sick people – the NSW chief health officer, Kerry Chant, put her name to the guidelines issued to cruise companies. Gupta still had reservations, arguing that the “medium-risk” level should be toughened so that all passengers should stay aboard until COVID tests had been resolved. Instead, this step was reserved for “high-risk” ships with confirmed cases. At the inquiry, commissioner Bret Walker would point out the obvious logical flaw: ships could conduct limited swabbing of passengers for COVID but could not test those swabs on board. How, then, could they know if they have confirmed cases?

A solution – collecting swabs from ships while still outside Sydney Heads, transporting them to onshore labs, getting them tested urgently in the hours before disembarkation – was in fact canvassed between the NSW port authority and NSW Health. Concerned about the exposure of pilots to COVID-positive swabs, the port authority’s acting chief executive, Emma Fensom, asked Australian Border Force on February 15 if they could help with a fast-tracking process for collecting swabs. Australian Border Force did not respond and the trail went dead.

The guidelines, then, placed a great weight on information provided to NSW Health by the ship’s doctor. It was assumed, among medical professionals, that such information would be dependable.

No actor in the Ruby Princess saga had experienced an event like COVID-19, but no single person needed to rely on instinctive judgements as much as Ilse von Watzdorf.

The South African national had been a medical practitioner since 2005, mostly in emergency departments, and a ship’s doctor since 2015, working on the Caribbean PrincessSun Princess and Regal Princess. She joined the Ruby Princess for two planned Sydney–New Zealand round trips, from February 24 to March 8 and from March 8 to March 21. On board, she headed a medical crew of three nurses, two paramedics and another doctor.

Von Watzdorf’s first trip saw a run of influenza-like illness among passengers and crew. She updated the responsible bureaucrat in Sydney, epidemiologist Kelly-Anne Ressler, on the symptomatic patients, more than 150 of whom self-isolated in their cabins. What caught the precautionary eye of NSW Health was the fact that two British passengers had just been in Singapore, so Ferson’s panel designated the ship “medium risk”. When the ship berthed in Sydney on March 8 and NSW Health officials, including Ressler and expert panel member Vicky Sheppeard, boarded to temperature-test an expected 150 passengers, they instead found 366 crowded into its Da Vinci Restaurant.

Sheppeard diagnosed 240 with symptoms of sudden-onset respiratory illness or flu. Five passengers and four crew were swabbed for COVID, and had to wait on board for their results. The other 2600 passengers were allowed to disembark, with instructions to go home and self-isolate.

It was a difficult day. The port authority pilots were angry after one of them, Jim Dargaville, had piloted the ship without any knowledge of suspected coronavirus cases on board. The pilots felt deceived by the ship’s captain, Commodore Giorgio Pomata, who had answered “No” to the question: “Are any crew members showing symptoms of the novel coronavirus on board or are there any ill passengers or crew on board?” Sarah Marshall, a senior port authority official at the harbourmaster’s office, said it was “a pure lie”. Pomata later apologised, saying he thought the question was asking whether there were any confirmed coronavirus cases on the ship, but the misunderstanding left a legacy of mistrust that would play out on the chaotic night of March 18–19.

The March 8 screening was also difficult for the NSW Health officers dealing with passengers’ anxiety over their travel connections, and the growing fear of a Diamond Princess “petri dish” scenario. All nine of the COVID swabs came back negative. As the new passengers boarded for the second voyage, von Watzdorf was looking for a quieter trip. She told Ressler, who handed her a box of 25 COVID swabs to take on the next sailing: “Hopefully they’ll behave this cruise.”

Von Watzdorf and Ressler immediately established a friendly rapport, and, once the Ruby Princess trip left on March 8, began to communicate via WhatsApp. Ressler signed off her messages with cheerful emojis. As the trip progressed, von Watzdorf informed Ressler about the growing sick list: “We’ve got a few people with sniffles.” On March 15, she emailed Ressler: “Hi, Kelly. We seem to be in the early phases of an influenza A outbreak on board. Luckily, they all seem to be presenting within 24–36 hours.”

One of them was Tony Londero.

Tony and Kerry Londero had been planning their Ruby Princess cruise since the previous November. Londero, a 62-year-old mining-industry worker from the Hunter Valley, and his wife were experienced cruisers, and booked the voyage to New Zealand with their good friends Paul and Linda Cheyne for $3458 per couple, all meals and entertainment included. Prior to the 13-day round trip, which would visit six New Zealand ports, they received letters from Princess Cruises advising them to take an extra two weeks’ supply of any medication they were on.

On March 8, the Londeros and Cheynes were among thousands of passengers held up for five hours at Sydney’s overseas passenger terminal while Ressler and Sheppeard were screening the passengers from the incoming Ruby Princess cruise and the nine COVID tests were pending. The Londeros, in a bar at the terminal, received text updates from Princess Cruises. They didn’t know the reason for the delay, but word got around that the staff on board were conducting a “deep clean”.

The new load of passengers embarked late in the afternoon, with the only unusual step a questionnaire asking them if they had been in China during the prior fortnight. “I was surprised that they weren’t checking passengers’ temperatures,” Londero said later.

Once aboard, the Londeros received their Princess Medallion, an electronic cabin key that could also be used for onboard purchases, and went to their cabin, A357 on “A” deck, before exploring the 290-metre ship. As well as swimming pools and entertainment areas, passengers could enjoy shows in the Princess Theatre, trivia contests and dancing classes in Club Fusion, gambling in Gatsby’s Casino, and multiple eating and drinking options in the Botticelli and Michelangelo restaurants, Horizon Court, the Crown Grill, Slice pizzeria, the Salty Dog Grill, Coffee & Cones, Café Caribe, Crooners Bar and the International Café. The Londeros and Cheynes sampled many of these options, as well as karaoke, art lectures and joining a choir, during the three days of sailing in rough seas before the Ruby Princess made its first port, at Fiordland on New Zealand’s South Island.

Londero first felt a sore throat and headache after the ship’s second stop, at Dunedin on March 12. He felt well enough to tour the next ports, Akaroa and Wellington, where Ilse von Watzdorf sent five swabs from passengers for coronavirus testing. All came back negative. Von Watzdorf, who had not been able to procure more swabs through her employer due to a worldwide shortage, asked for more, but acknowledged to Ressler that on the previous trip the New Zealand medics were “not as forthcoming as I hoped they would be”.

The cruise company had ordered more swabs to be waiting for the Ruby Princess at Auckland, but the ship would not make it there. On March 13, two days after WHO declared COVID-19 an international pandemic, Princess Cruises decided to end all trips. “Sensible decision!” Ressler messaged von Watzdorf. “Hope you get a nice break and other lines follow soon.”

The Londeros were not unaware of the global outbreak. After seeing a television report about deaths in Italy, they and the Cheynes decided to practise social distancing, staying in their cabins as much as possible, though there was no requirement to do so from Princess Cruises. Commodore Pomata announced, to great cheers, that the ship would complete its full itinerary. But on March 15, after Prime Minister Scott Morrison announced that no cruise ship arrivals would be accepted into Australia other than four exceptions including the Ruby Princess, Pomata announced an immediate return to Sydney via Cook Strait, arriving on March 19 instead of March 21.

By this stage Tony Londero’s health had taken another dive, and when a note was slipped under his cabin door on March 16 asking all unwell passengers to report to the medical clinic, he went to see von Watzdorf, who swabbed him for influenza and COVID-19. To encourage any waverers to report, passengers were informed that visits to the clinic were free of charge. When Londero’s flu test came back negative, von Watzdorf said, cryptically, “They aren’t going to be happy.” Coronary irregularities indicated he’d had a mild heart attack during the cruise, and von Watzdorf said she would organise an ambulance to take him to hospital once the ship berthed in Sydney.

The healthy passengers were still having a fine time. Precautions included regular use of hand sanitiser, more conspicuous cleaning, promotion of symptom awareness, changes from self-service to table service of food and drink, and instructions to avoid public toilets where possible. But social distancing was not generally practised; at a St Patrick’s Day event, about 400 guests attended a party after a show at the Princess Theatre, before a farewell party in the ship’s atrium on March 18.

Another world was unfolding in the sick bay, where Tony Londero was far from the only unwell passenger. From March 17, he heard 77-year-old Lesley Bacon in a nearby bed, short of breath, coughing and suffering from a trapped femoral nerve. Passengers would generally avoid reporting sick due to the high cost of medical treatment on cruise ships, but with the waiving of fees there was a flood of anxious and unwell people keeping von Watzdorf working 19 to 20 hours a day. By the second-last day of the cruise, she recorded more than 100 cases of people with influenza-like illness and acute – meaning sudden-onset – respiratory illness. Greg Jackson, a Carnival executive in Sydney, emailed a colleague: “the Ruby numbers gone berserk in the last 48 hours”. The cases were piling up so quickly, von Watzdorf was having trouble maintaining the Acute Respiratory Diseases (ARD) log, a document the ship was required to share with the government. She correctly followed the NSW Health obligation to provide the log “at least 24 hours” before arrival, but during the last day, the number of passengers with flu and respiratory illnesses passed 1 per cent of the total – a critical, if arbitrary, threshold that the NSW Health assessment panel had set to determine the ship’s risk level. The crossing of this threshold remained unreported until the ship had disembarked.

After the five negative COVID-19 tests in Wellington and 24 positive flu tests on board, von Watzdorf thought she was dealing with an influenza A outbreak. It was not known whether a patient could have both flu and coronavirus, but von Watzdorf noticed that patients were getting better after taking oseltamivir, a medication used for flu.

As the Ruby Princess and other liners headed for Sydney to beat Morrison’s deadline, the panel assessing the health risk of cruise ships – Tobin, Ferson, Forssman, Sheppeard and Isabel Hess, deputising for Gupta – struggled with their workload. They assessed 63 cruise ships that month. Late on March 15, Hess emailed Gupta: “I think we are close to breaking point… We barely coped today.” After the port authority complained on March 16 about an incident involving the Pacific Explorer, NSW epidemiologist Ressler replied, “All I can do is apologise, it’s probably more because I can’t keep up.” Professor Ferson described himself as “hellishly busy”, receiving 255 emails and dozens of phone calls on March 18 alone, while dealing with four incoming cruise ships. Tobin was simultaneously leading the response to a COVID outbreak at the Dorothy Henderson Lodge in Sydney’s west. 

Aboard the ship on the morning of March 18, hotel manager Charles Verwaal emailed his company’s port agents to outline a staggered disembarkation procedure the next night, to get guests off quicker due to “more early flights and most likely expected scrutiny at the airport”. Guests were “anxious to leave the vessel and will deal badly with unnecessary delays”, he wrote. “We do not want unnecessary delay since we don’t know what is on our path … after an already emotional cruise.” The ship notified the port authority that it would come in soon after midnight.

Verwaal was expecting NSW Health to board the ship, in a repeat of the “medium-risk” procedure of March 8. But the information von Watzdorf was providing NSW Health was leading to a different conclusion. The expert panel was less concerned about conditions on the Ruby Princess than they had been on March 8. There were again no confirmed COVID cases and, unlike the previous cruise, no passengers had recently visited east Asia. Crucially, the panel of doctors had overlooked a recent change to the epidemiological definition of a “suspect country”. This definition, issued by Communicable Diseases Network Australia, now included all international travel. Hundreds who met this definition, including 512 American passengers, were aboard. Some members of the panel later admitted that this change to the CDNA definition should have led them to upgrade the Ruby Princess to “medium risk”. But even if they had, they would still have let the passengers disperse after onboard screening, repeating the steps they had taken on March 8.

The fateful meeting to assess the incoming ship – via email – took place from 1pm on March 18. Ferson emailed his colleagues: “Ruby Princess – probably low [risk], but higher rate of ARI (none are travellers), but ILI <1% and flu A POS, needs discussion about getting swabs to the lab.” That is, he wanted the COVID swabs in von Watzdorf’s fridge tested as quickly as possible, but not at the expense of holding up the disembarkation.

At 1.11pm, Forssman replied: “Thanks Mark, I agree with low risk for all three [ships], but swabs needing to be tested from Ruby Princess. Not sure about how they will get from [the overseas passenger terminal] to the lab at midnight though. Can the cruise company arrange transport?”

At 1.52pm, Hess emailed: “I agree low risk all three and also agree swabs need testing.” Sheppeard concurred, and at 2.17, Tobin completed the unanimous decision: “I also agree low risk. Also happy with the testing plan.”

Ferson contacted the lab at Prince of Wales Hospital, who told him they would not be able to test the swabs until 10am the next morning, “which is OK as long as you guys agree”, Ferson told the other panellists.

At 3.14pm, Ressler passed this information to a surprised von Watzdorf on the boat. The cruise company executive in charge of its incident-response team, Peter Little, had emailed his colleagues on March 17 saying he expected the Ruby Princess to receive a medium- or high-risk assessment. On board, Charles Verwaal was taken aback: “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 Walker inquiry.

There was some confusion at the harbourmaster’s office, where senior port authority official Sarah Marshall said she was “hearing whispers” that the ship’s risk level might be upgraded, but at 5.07pm Ressler sent out a formal notification that the Ruby Princess was low risk, and passengers would be allowed to travel onward with instructions to self-isolate for 14 days. The die was now cast – until a tragicomic misunderstanding nearly stopped the boat.

On March 18, duty harbourmaster Cameron Butchart had started work at 7.30am. Though he was working from home he had responsibility for allowing ships in or out of the harbour, through assessing their requests for a pilot.

For more than a week, the harbourmasters had been less than happy with the safeguards given to their pilots. The port authority’s Sarah Marshall queried the process with Kelly-Anne Ressler, who told her that NSW Health wanted to get people off ships; they didn’t want a Diamond Princess situation, and would prioritise the elderly. Marshall tried to obtain access to each ship’s Maritime Arrivals Reporting System declaration, the health summary they were required to supply to the federal government. But the Department of Agriculture turned down this request, sending the harbourmasters back to NSW Health.

The pilots were unimpressed. They heard that another Princess Cruises ship, the Grand Princess, had quarantined COVID-positive passengers off the Californian coast on March 9. They thought this safer approach should have applied to the Ruby Princess on March 8. They were already angry with Commodore Pomata, who had replied “no” to their question about sick passengers on board the previous, March 8 cruise. One of the pilots, Martin White, said Pomata was “a bit of a shonk”. The deputy harbourmaster, Steve Howieson, agreed: “That’s why we’re really onto him.” Another of the pilots, Neil Mackenzie, emailed colleagues on March 10: “Surely everyone should have been kept on board until testing took place & then, quarantined if a positive result was detected. Instead the health authorities allowed approximately 2500 people who may have been contagious to just walk off the ship onto the streets of Sydney. Is this a serious response?”

Marshall replied that NSW Health was “the combat agency” and “this is not in our remit”.

So, despite their misgivings, the harbourmasters were in NSW Health’s hands. On the afternoon of March 18, Marshall told Butchart that the Ruby Princess would arrive after midnight and, although it had sick people aboard, two requiring ambulances, it had been cleared as “low risk” by NSW Health. Despite his misgivings about the Ruby Princess from the March 8 experience, Butchart thought, “This is great, NSW Health have got this in hand.”

His confidence was shaken at 10.44 that night, however, after a strange phone call came in from Peter Dilonardo, a senior officer at Ambulance NSW, claiming there were “two coronavirus cases” on board a Carnival ship coming in that night. Dilonardo wanted protection for his ambulance officers. Steve Howieson took the call. Uncertain about Dilonardo’s grasp of the facts, Howieson and Butchart wondered if the caller might even be a hoaxer or a journalist impersonating an ambulance officer. At 11pm, Butchart refused pilotage to the Ruby Princess while he set about investigating.

The confusion stemmed from a sequence of phone calls that resembled a game of Chinese whispers. That afternoon, Ilse von Watzdorf asked one of Carnival’s port agents in Sydney, Bibi Tokovic, to organise ambulances to Royal Prince Alfred Hospital for Tony Londero and Lesley Bacon early the next morning. Von Watzdorf said the patients had “no confirmed diagnosis”, but had been swabbed for COVID-19, so ambulance officers should wear personal protective equipment.

At 7pm, Tokovic, reading her notes from von Watzdorf’s call, phoned Ambulance NSW.

“They’re infectious,” Tokovic told ambulance staffer Ashley Nguyen. “They’ve got upper respiratory tracts and they have severe lower back pain … We’ve been requested by New South Wales to take them to the Royal Prince Alfred.”

“So is he [Londero] infectious?” Nguyen asked.

Tokovic answered: “So the doctor has told me they’ve been tested for coronavirus so precautions need to be taken, so possibly.”

Nguyen took this to a dispatcher, Naomi Mannion, who called Tokovic to ask her to confirm what she had told Nguyen. Tokovic said Londero and Bacon were not on oxygen but “just to make sure that, you know, they could potentially be infectious”.

Royal Prince Alfred Hospital had no knowledge of suspected coronavirus patients coming from the Ruby Princess. Mannion informed her superior, Andrew Bibby, who asked, “In that case, why aren’t we setting up a screening point like with the airports, like Public Health there, or are they there – do Public Health know about this?”

NSW Health did know about it, but its expert panel had already cleared the Ruby Princess to disembark and had finished work for the night.

At this point, Dilonardo made his alarming call to the port authority.

After denying pilotage to the Ruby Princess, Butchart tried to verify Dilonardo’s authenticity and to find the source of his information about “two coronavirus cases”. Butchart called Dilonardo himself, and while commenting later that the ambulance officer “didn’t pass the pub test”, believed him enough to try to call Carnival for corroboration. But Tokovic, planning to meet the Ruby Princess at Circular Quay around 2am, had gone to sleep and turned off her phone. Other Carnival port agents were also uncontactable. Dilonardo, unaware the port authority and police suspected he was a hoaxer, was frantically trying to reach NSW Health, but only got a coronavirus hotline.

The Ruby Princess was still sitting off Sydney, unaware that it was being denied a pilot. At 11.52pm, Butchart emailed Howieson: “Please continue to raise the ship and advise the ship their booking is denied.”

At midnight, Emma Fensom emailed her port authority staff: “We have been advised, within the last two hrs, by NSW Ambulance that RPA Hospital has been notified that there are persons on board Ruby Princess with COVID-19. Ruby Princess was due to enter Port Jackson at 0300 Thursday morning. We have not been able to get anyone from NSW Health for further information/assistance. We have delayed pilotage of the vessel until we receive guidance from NSW Health.”

Unable to contact the ship, the Carnival company or NSW Health, port authority officers kept trying to solve the problem. Were there confirmed coronavirus patients aboard? Could Dilonardo’s information be trusted? To break the impasse, Butchart’s immediate superior, Rob Rybanic, said he had a number for Paul Mifsud, the head of Carnival’s port operations for the Asia-Pacific region. Rybanic’s 11.54pm call to Mifsud’s mobile wasn’t answered, but Mifsud phoned him back from his kitchen at midnight to assure him that there had been a mix-up: no, the ambulance patients were not coronavirus cases and, yes, NSW Health had cleared the ship. Rybanic relayed this to Fensom, who wanted it confirmed herself. Mifsud got von Watzdorf to call the port authority at 12.09am. The ship’s doctor told Howieson that the ambulance passengers, Londero and Bacon, had not tested positive for COVID, and confirmed that NSW Health had cleared the ship as “low risk”. It was the first time in 10 years as a harbourmaster that Howieson had ever spoken directly with a ship’s doctor. By 12.49am, after another series of calls, the port authority reversed its decision to deny pilotage. The panic set off by Dilonardo’s calls, it seemed, was all for nothing.

In good weather, with a light northerly breeze, Sam Chell boarded the Ruby Princess at 1.08am, wearing gloves and a mask for protection, to steer it through Sydney Harbour into Circular Quay.

Even as Chell had control of the ship, there were more miscommunications. The ship’s clearance by NSW Health still hadn’t been passed down to the ambulance service. Dispatcher Naomi Mannion called her boss, Andrew Bibby, and said they had to pick up “two query coronavirus patients” from the Ruby Princess.

“It’s controversial because we’re not meant to be having cruise ships dock, is that correct?” Bibby replied.

“That’s correct, if they’re, you know, query corona.”

“And they’re only docking to offload these patients?”

“Well, that’s the other thing that we can’t confirm. We don’t know if they were just offloading the two or if they’re offloading, like, if the whole ship is coming in. Potentially I think the whole ship is going to be offloaded tomorrow.”

Moments later, after confirming that the ship was docking, Mannion called Bibby again: “Whether or not they will be disembarking the entire ship tomorrow morning I have no idea.”

By now, confusion about the “query corona” patients had reached Australian Border Force, which woke Cameron Butchart at 2.15am, wanting to “alert me that the ship may need to go back to sea. I advise them to act ASAP as at this stage the Ship was within Port limits.” Butchart checked his Marinetraffic app and located the Ruby Princess passing Taronga Zoo. He told the ABF officer the ship could still be held back, but “you have about 20 minutes to make a pretty quick decision before I can’t turn the vessel around”.

Five minutes later, having consulted with a superior, the ABF officer called Butchart. “Bring it in,” she said. Butchart went back to sleep.

After a brief trip to his cabin to have a shower, see Kerry and organise his luggage, Tony Londero returned to the ship’s clinic and prepared for the ambulance crew, who came on board to take him just after 3.30am. Lesley Bacon, who had not been well enough to leave the clinic, went in another ambulance.

When the Ruby Princess berthed, von Watzdorf was still surprised by NSW Health’s decision not to screen the ship, but “it is not my decision to make,” she told the inquiry. “If it was my decision, I would have perhaps waited, like the previous time.” Princess Cruises had three levels of warning for illness on board – green, amber and red – dictating matters such as how much intense cleaning took place. Since February, the level had remained on red. Von Watzdorf said that if any government agency had asked her “if there was a possibility of COVID-19 being on board”, she would have answered yes. But the question their form asked was: “Has any person on the vessel been in contact with a proven case of novel coronas infection in the last 14 days?” She answered “N”.

Bibi Tokovic collected the triple-bagged COVID swabs from von Watzdorf and gave them to a driver who took them to Prince of Wales Hospital. At 6am, after passenger gangways were connected, ABF and Department of Agriculture staff boarded to obtain paperwork, check the passports of any crew who had joined the ship in New Zealand, and collect passenger cards.

The ABF’s role in all this hardly measured up to Minister Peter Dutton’s thrusting comments and Prime Minister Scott Morrison’s assuring announcement on March 15 that “there will be some bespoke arrangements [for cruise ships] that we put in place directly under the command of the Australian Border Force to ensure that the relevant protections are put in place”. On the morning in question, three ABF staff conducted rudimentary tasks such as handing out brochures to incoming passengers about home self-isolation. Ressler asked the ABF’s man on the scene, Franz Odermatt, “All are ok to debark but all to go into home isolation due to the new rules. Do you know if ABF are enforcing this?” Odermatt replied, “Yes, we are handing out the notice for isolation to all disembarking pax and crew here at seaports, I’m not sure how this is monitored once they get home.” Even when the all-important Commonwealth function of granting pratique to the Ruby Princess occurred at 7.39am – after passengers had begun disembarking – nobody at ABF could tell the inquiry who had carried out this task. Little wonder that Commissioner Walker – after remarking that whenever “‘F’ stands for force, in this country at least, [it] opens itself up to rather sardonic comment about its pretensions” – made the observation that “I’m not quite sure how the ABF comes into this … It can’t be said that the ABF played any role in the public health clearance of this ship … [It] may have played a complicating role in the consequences in terms of public health of what happened when people scatter.”

From 7.14am, in groups of 50 to 100, the passengers got off the Ruby Princess and began to scatter. Many would remark that it was the fastest they were ever moved off a cruise ship. By 10.44am, aside from the 11 waiting for their COVID swab results, all the passengers had left the ship, to crowd around the taxi and bus stands at the terminal, where they would begin their onward travel around Australia and the rest of the world.

Workers at the port authority were fuming over the night’s events. At 10.19am, Sarah Marshall emailed Ressler saying “there was a lot of uncertainty about what was happening with the [Ruby Princess] in the early hours of the morning. Can you please tell us who we can contact from Health during the night to ask questions and get clarity?” Julie Taylor from the port authority asked Tokovic from Carnival why they hadn’t been told there were 120 passengers in isolation in their cabins. Tokovic replied: “There is no reason we would normally let you know.” Cameron Butchart called Ambulance NSW to ask if Bacon and Londero had coronavirus, and grew frustrated when given no answer. He then contacted Valerie Burrows, the senior port agent at Carnival, to ask why there had been so much confusion the night before; Burrows explained that Tokovic had got her information about “infectious” passengers wrong.

Von Watzdorf’s work was far from done. She still had 1057 crew on board, some of whom were sick. Thinking the 13 COVID swabs – Londero and Bacon plus the 11 remaining quarantined travellers – would be tested immediately, von Watzdorf messaged Ressler at 2.38 that afternoon: “Do we have anything yet?”

Ressler checked the online system. The specimens had not been logged. Ressler phoned the lab, who, overwhelmed with COVID work, said they would do them on their next run.

In a message to von Watzdorf, Ressler said “results won’t be through till midnight. I’ll get them to you early morning. Sorry, just lots of specimens.” Von Watzdorf replied, “I completely understand. Just somewhat anxious to know.”

At the inquiry, Walker would raise questions about the lab’s lack of urgency, to which Ressler replied: “My understanding is that the technician didn’t realise that they were cruise ship samples and so they were just put into the queue as per normal. They weren’t tested as priority. Having said that, this was a low-risk ship, and I hadn’t escalated for the specimens to be tested as a priority.” NSW Health was battling to keep up with the pandemic: on that day, just 11 laboratories tested 6363 swabs for COVID-19.

Late that night, word filtered out: Bacon and Londero tested positive for COVID-19, as had a Filipino buffet steward still on board, 32-year-old Ben Marbiog.

The next morning, Ressler informed von Watzdorf, who replied, “Good luck with tracing the guests now.” She appended her message with three emojis of screwed-up faces.

Ressler messaged, “For what it’s worth, I’m sorry that this is now your problem, as much as I’m sorry it’s my problem. We almost made it.”

“So close, yet now so far,” von Watzdorf responded.

At 5pm, Ressler noticed that another corona-positive passenger, Kim Walters, was not on the Acute Respiratory Diseases log supplied on March 18.

“Did you add any more patients after you sent it to me, and do you have an updated log?” she asked von Watzdorf, who replied: “I’ll send it now. Sorry, I forgot. The last one was from the morning. It was so crazy.”

Over the next few days, the outbreak spread among the 1057 crew still on the ship as it remained in Sydney. Within weeks, 202 of those crew would test positive. On April 1, von Watzdorf sent Ressler a WhatsApp message: “I keep asking myself what I could have done better to protect people.” Ressler replied: “Yeah, there will be a – there will be more cases, probably a lot.”

Kerry Londero travelled with Tony in the ambulance, but on arrival at Royal Prince Alfred, Tony had a seizure and was put in the intensive care unit. Lesley Bacon was also sent to ICU, where she passed away two days later.

The third passenger to test positive, Kim Walters, was notified of her result while waiting in the Virgin lounge at Sydney Airport for her flight home to Queensland. She was rushed to RPA and within days was on a ventilator. She would be in an induced coma for three more weeks, but eventually recovered, though by the time of the commission of inquiry in June, she was still unable to speak.

Tony Londero was discharged to a “virtual hospital” in Summer Hill after eight days, and went home four days later. Kerry also contracted the virus, but neither blamed the ship’s staff. On April 20, Kerry wrote to von Watzdorf: “You have certainly been through a harrowing time and we are so sorry for that. Tony and I are now home in Qurindi which we are extremely grateful for. Tony became very ill and … almost succumbed to the virus but pulled through. He is still very weak and becomes tired very quickly. But we would like to thank you and your beautiful nurses for the care and kindness you showed to myself and Tony … As I said to you when we left the ship our home is open to any of you.”

Other passengers diagnosed with the virus did blame Princess Cruises, and by midyear were contemplating a class action. Within two days of its arrival, the Ruby Princess had 26 confirmed cases. By then, dozens of the 512 American passengers had flown home, many coughing and sneezing throughout a Qantas flight to Dallas. Another implication had fallen through the net at NSW Health. Kelly-Anne Ressler had raised with the expert panel the possibility that passengers awaiting COVID-19 tests shouldn’t be allowed to fly, but, she admitted, “I can’t find anywhere that I followed that up … It was likely an oversight on such a busy day.”

By early April, there were 342 confirmed cases from the Ruby Princess. In Tasmania, an outbreak of 114 cases at the North West Regional Hospital in Burnie was found to stem from two inpatients admitted after contracting COVID-19 on the Ruby Princess. By June 13, there were 371 primary cases from the ship in New South Wales alone, resulting in nine deaths locally, plus at least another 300 cases and 12 deaths elsewhere.

It fell to the inquiry commissioner, Bret Walker, to work out how the processes that contributed to the debacle might be improved. His commission was not a witch-hunt, he maintained, but it was quickly able to isolate the flaws in the decision chain at NSW Health. The agency released a report in late March, defending its processes as “well in advance” of federal requirements: “NSW Health undertook a full assessment of the Ruby Princess, notwithstanding under the National Protocol in place, it could have chosen not to do an assessment.”

Walker was not to be fooled. He directed some pointed questions at NSW Health, starting with Kerry-Anne Ressler, who was reduced to tears during her appearance. Walker questioned the members of the expert panel who let the Ruby Princess dock in Sydney and the passengers to disperse to taxis, buses, trains and aircraft to spread the outbreak around the country and the world. Ferson, Tobin, Sheppeard, Forssman and Hess said that the guidelines they had written up weren’t to be applied in black and white, but required something of the medical practitioner’s art. Walker asked Tobin if, in practice, this meant they would send possible coronavirus-carrying passengers out into the world and “hope for the best”. Tobin preferred to call it “a precautionary approach”.

The panel conceded that, on epidemiological grounds, they could have rated the ship medium-risk, but they still would have let the passengers disembark after temperature-testing them. Only if confirmed coronavirus cases were on board would they stop disembarkation, and, as had become clear by then, this was a logical impossibility: at the time the 2670 passengers were on their buses, taxis and planes, the positive swabs were sitting, untested, in a lab.

Walter pressed: why not just hold all passengers aboard until the test results were known? Tobin replied: “Certainly with the benefit of hindsight we – I – may have done things differently, but I think one of the things that was weighing on our mind was the impact on those couple of thousand passengers.” For passengers who were not feeling sick, to wait another six to nine hours on the ship after it had berthed “does seem like a long time to me”.

“There’s the inconvenience,” Walker said. “They’d like to get home, which we all understand. And there is the risk to them of being infected in those next few hours, which is a real one … [But] they could all be confined to their cabins, couldn’t they? Not much fun, but then neither is COVID-19.”

“That’s certainly one possible option,” Tobin replied. “I think we will all have liked to have done that, but we were informed by the best evidence we had at the time. And – and it changed very quickly.”

At the centre of Australia’s response to the COVID outbreak was politicians’ surrender to the expertise of medical practitioners. By global standards, Australia’s had been a remarkable success. The Ruby Princess can be seen as an exception, but Professor Mark Ferson, the leader of the panel of doctors, maintained that he and his colleagues had been right not to exercise a more draconian quarantine and to reject Leena Gupta’s and David Durrheim’s warnings. He wanted to protect the under-resourced NSW Health staff who were dealing with three other cruise ships that same day. He thought the steep rise in patients at von Watzdorf’s clinic in the final hours of the trip was more likely a result of the waiving of consultation fees on board than a coronavirus outbreak. He didn’t think the Ruby Princess was of such a high risk that the COVID swabs should have been tested more urgently. Overall, Ferson said, “It was always our intention that passengers would be disembarked from cruise ships as quickly as possible, in all the circumstances. This is because remaining on the ship would greatly increase their risk of infection, as was shown to have happened on the Diamond Princess.” Ferson’s view was supported by an independent report by UNSW professors Anthony Kelleher and Andrew Grulich on June 17, who wrote: “The 337 passengers who developed COVID-19 acquired it while on board the ship. It is likely that many more cases were averted by their early disembarkation into self-isolation at home… It is our opinion that the findings of investigations into the prior Diamond Princess case support this assertion.”

Compulsory hotel quarantine – NSW’s eventual solution – was introduced after the Ruby Princess passengers went out into the world. As Vicky Sheppeard told the inquiry, the public’s expectations were changing from one week to the next: “Even comparing one week to another in that period, there was different acceptance of public-health measures compared to the risk.”

Much of Australia’s response to the COVID-19 outbreak has been based on a faith in the old saying that “doctor is right”. The Ruby Princess showed the limitations to this faith, when, amid a fast-changing public health crisis, there was a convergence of bad organisation, bad systems design, bad communication, a legacy of bureaucratic rigidity, and a set of guidelines that was, in Walker’s words, “doomed to inadequacy” – not to mention plain bad luck. His inquiry neither sought nor found a villain, nor indeed found that anyone had failed to follow the steps that had been laid out for them on the day. The operation was a success, as it were, and yet at least 21 patients lost their lives. This harrowing fact would exercise its own silent judgement.

Malcolm Knox

Malcolm Knox is a former literary editor of The Sydney Morning Herald, and has won three Walkley awards for journalism. His books include Jamaica, The Life and Bluebird.

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