The Ruby Princess cruise ship was allowed to dock in Sydney in March in the midst of the coronavirus pandemic and allow almost 2,700 passengers to disembark.
It also failed to get quick test results for unwell passengers before they disembarked.
Overall, Victoria reported another 279 virus infections across the state on Sunday, taking the total number of active infections to 7671.
When COVID-infected passengers were allowed to disembark the now-infamous Ruby Princess cruise ship in Sydney the errors were "inexcusable", "inexplicable" and the results deadly.
Eleven of those 16 deaths were linked to aged care.
The delay was "inexcusable" and the swabs should have been tested immediately, Mr Walker said.
"In light of all the information the (NSW Health) Expert Panel had, the decision to assess the risk as "low risk" - meaning, in effect, "do nothing" - is as inexplicable as it is unjustifiable", the report said.
The 320-page report from the Special Commission of Inquiry into Ruby Princess, launched on April 15, was sent to New South Wales Premier Gladys Berejiklian.
The NSW Government then erred by allowing disembarked passengers to immediately travel interstate and overseas, breaching the state's public health order that came into effect two days earlier.
Princess Cruises said the report confirmed none of its staff misled public authorities who oversaw the vessel's disembarkation.
Victoria state said 25 individuals had actually passed away from COVID-19 in the previous 24 hr, more than the previous worst everyday toll of 21 reported nationally on Aug 12. Victoria has recorded 107 deaths in the past seven days.
Australia's coronavirus tally stands at 22,739 infections and 375 deaths, a lot of them in Victoria. "I would not read too much more into that, it is simply the product of multiple days' work being brought to book, as it were, recorded in our numbers", he said.