NSW Health officials have been held responsible for the Ruby Princess cruise ship debacle.

The NSW Health department has been accused of serious, inexcusable and inexplicable mistakes in a report into the decisions to allow 2,647 passengers who disembarked the cruise ship in Sydney on March 19.

The report by Bret Walker, SC, from the Special Commission of Inquiry into Ruby Princess, says NSW Health made serious mistakes in its handling of the Ruby Princess, including delays in sending swabs for COVID-19 testing and assessing the ship as low risk.

Three COVID-19 tests performed on board returned positive within 24 hours of the passengers disembarking at Circular Quay and being free to travel home.

Up to 700 passengers and 202 crew tested positive and 22 people died in the following weeks. The passengers went on to infect 19 people in NSW and 15 people interstate.

Amid the criticisms of NSW Health, Mr Walker's report found senior doctors were forced to make decisions at “a time of stress” when they were “stretched to their limits by their workloads”.

“This neither absolves those professionals of their responsibilities nor lessens the level of care expected of them in the performance of their duties. It is, however, an appropriate human (and humane) matter to take into account in any critical analysis of their actions and decisions,” the report says.

“Despite how it may sometimes seem, the decisions of the physicians within NSW Health concerning the Ruby Princess were by no means the only decisions made by either those physicians or others within the NSW Health bureaucracy since the emergence of COVID-19.”

NSW Health Minister Brad Hazzard has told senior colleagues that the Health officials have his complete support.