NSW Health missed a "significant spike" in the number of sick people on board the Ruby Princess ahead of its docking in Sydney on March 19, then allowed an "inexcusable" delay in testing a dozen swabs taken on board, says a report by the special commission of inquiry into the Ruby Princess debacle.

All 2647 passengers on board should have been tested for COVID-19, and disembarkation should not have occurred until the test results were in, says the 315-page report by Commissioner Bret Walker, SC, which was handed to the NSW government on Friday.