Gladys Berejiklian has apologised for the suffering caused as a result of the "horrible" mistakes made by NSW authorities which led to the countrywide spread of COVID-19 from the Ruby Princess cruise ship.
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The NSW premier spent the weekend reading the damning findings of a special commission of inquiry into the fiasco after the report was publicly released on Friday.
"I want to apologise unreservedly to anybody who is continuing to suffer or has suffered unimaginable loss because of mistakes that were were made within our health agencies," she told reporters on Monday.
"Those circumstances should and never will happen again in NSW.
"We have learnt so much since those horrible mistakes."
The premier extended her apology in particular to the 62 people who weren't on the ship but became infected with COVID-19 as a consequence of errors made.
The inquiry headed by Bret Walker SC identified a series of "inexcusable," "inexplicable" and "unjustifiable" errors NSW authorities made before and after 2700 cruise ship passengers were allowed to disembark at Circular Quay in March.
In the report, Mr Walker reserved his harshest criticism for NSW Health, while relieving Australian Border Force officials of blame.
The ship - which was low on medical supplies and swabs for COVID-19 tests due to shortages - left Sydney on March 8 for New Zealand and returned 11 days later.
Passengers were allowed to disembark before the results of 13 expedited tests, which showed at least three people had the virus.
The delay was "inexcusable" and the swabs should have been tested immediately, Mr Walker said.
He found the NSW government also erred by allowing the disembarked passengers to immediately travel interstate and abroad, breaching a new public health order.
Passengers were able to leave the ship as it had been deemed "low risk" as only 0.94 per cent had reported flu-like symptoms and visited virus-hit nations.
The one per cent marker required to mandate NSW Health intervention had "limited" utility for assessing if COVID-19 was on board, the commission found.
The premier said the NSW government would implement all recommendations and the biggest lesson had been in relation to risk assessment.
Ms Berejiklian noted that had Mr Walker found there were systemic issues that led to the debacle, she would have taken action immediately.
She insisted her role now was to ensure the state deals with the pandemic by having a "continuity of people" in expert roles.
Chief Health Officer Dr Kerry Chant and Health Minister Brad Hazzard also apologised for the errors made.
Dr Chant noted the staff involved had recognised that in hindsight different decisions would have been made.
"No one wants to make this error in judgment," she said.
"It has had a toll on those individuals."
NSW Opposition Leader Jodi McKay praised the premier's comments which she described as genuine and sincere.
"I hope it does go some way to healing for many of those who have been impacted as a result of the Ruby Princess," she told reporters in Sydney.
The Australian Medical Association said the inquiry provides an opportunity for officials to learn from the situation and improve their response in the future.
The inquiry revealed the Ruby Princess outbreak infected 663 passengers and led to 28 deaths, including 20 in Australia and eight in the United States.
Australian Associated Press
