28-05-2025
Inquest told toddler Pippa White's sepsis and pneumonia death preventable
Medical experts have told an inquest the medical system failed a toddler whose death from sepsis and pneumonia was preventable.
Two-year-old Pippa Mae White died after going into cardiac arrest at Orange Hospital in central west NSW on the afternoon of June 13, 2022.
She was transferred there from Cowra Health Service the night before.
Paediatric intensive care specialist at the Royal Children's Hospital in Melbourne, Dr Warwick Butt, gave evidence at the inquest on Wednesday.
He said if her condition was recognised earlier, and treated properly, he would expect her to have survived the illness.
"This is a tragedy that was avoidable," Dr Butt told the inquest.
Infectious disease specialist at Canberra Hospital, Dr Phillip Braslins, concurred.
Pippa's heart rate was in the "red zone" for a child potentially having sepsis, according to a NSW Health policy document, when she arrived at Cowra Hospital on June 12.
The inquest heard the paediatric sepsis pathway guide required a rapid response be called based on her heart rate alone, and would trigger further actions to help diagnose or rule out the condition.
The two-year-old was not placed on that pathway at either the Cowra or Orange hospitals, and all six medical experts thus far have told the inquest she should have been.
Senior specialist in emergency medicine at St Vincent's Hospital, Dr John Raftos, said it should be followed "without nuance".
The inquest heard "grunting" noises made by the toddler, present from the time she arrived at Cowra Hospital, were a dangerous indicator of how ill she was.
Mother Annah White took videos of her daughter making the noises which were previously shown to the inquest.
"That was a fundamental sign that reflects rapidly progressing and severe lung disease," Dr Butt said.
The inquest heard that health professionals at Cowra did not see the symptom despite the doctor assessing Pippa with a stethoscope.
Paediatric emergency physician at the Monash Medical Centre in Melbourne, Dr Simon Craig, said he could not explain why up to seven people missed the symptom during the toddler's treatment.
"I would assume the grunting was there more often than not," he said.
"[But] grunting is relatively rare. As a junior doctor I may not have appreciated grunting as I do now.
"The more senior you are the more obvious it is."
The inquest was told the medical assessment of Pippa the night she was transferred to Orange Hospital failed to recognise the true nature of her illness.
Dr Craig said the examination by Dr Christoper Morris documented the symptoms but did not interpret them correctly.
Paediatric sepsis expert Dr Adam Irwin from the Queensland Children's Hospital in Brisbane said it highlighted why the pathway tool should have been used.
"Unfortunately they were anchored in a diagnosis that had already been reached [of a viral infection]," he said.
"For far too long they were anchored to that and failed to see the signs of deterioration."
Dr Braslins said her condition should have prompted blood tests being conducted when she arrived at the hospital which would have charted a different course of treatment.
Blood tests were not ordered for the toddler until the early hours of the following morning after she had deteriorated further and recorded a red zone heart rate of 196 beats per minute.
Dr Craig said the "make or break" in her treatment was the lack of intervention when she became "critically ill" between one and two o'clock in the morning.
The inquest heard the blood tests, starting antibiotics, and introducing IV fluids should have commenced earlier than that.
"The deterioration could almost only be attributable to sepsis," Dr Irwin said.
"The intervention should have been started … and [not doing so] introduced an unnecessary delay."
The inquest has been adjourned until later this year when it will hear further expert evidence across two hearings.
