The parents of a two-year-old girl who died of septic shock after she was misdiagnosed by doctors in regional New South Wales believe her death was “totally avoidable”, an inquest has heard.
Pippa Mae White died on 13 June 2022, two months before her third birthday, after doctors at the hospitals in Cowra and Orange assumed she had an acute viral illness, rather than the bacterial infection that resulted in her death.
The NSW deputy state coroner, Joan Baptie, is examining whether Pippa’s death was preventable and whether she received appropriate care at the hospitals, and from the Newborn and Paediatric Emergency Transport Service (Nets) team.
Her mother, Annah, read a statement at the inquest on Thursday with her husband and Pippa’s father, Brock, sitting beside her.
“It is our personal opinion that Pip’s death was totally avoidable. We will never be whole as a family again,” Annah said.
“We as your parents promise to spend the rest of our lives advocating to stop this from ever happening again … Your death will not be for nothing.”
Annah described her daughter as “the most perfect angel in the world” and said she had been compassionate, empathetic and sensitive even at such a young age.
The inquest was shown a 25-minute montage of photos and videos of Pippa’s short life; playing with her twin brother Leo and her older siblings Lucy, Tamika, Sophie and Bodhi and their parents and grandparents.
A quilt made out of Pippa’s clothes was draped over the witness box at the coroner’s court in Lidcombe. A photograph of the young girl running through a field of flowers was displayed next to it.
Her family and friends, dressed in her favourite colour, yellow, wept as the video played. It ended with photos of Pippa in her coffin and footage of Lucy and Leo visiting their sister’s grave.
Pippa presented to Cowra hospital about 2pm on 12 June 2022 with a fever, vomiting, and an elevated heart rate, the inquest heard.
She did not have a blood test done until 4am on 13 June, more than eight hours after she was transferred to Orange hospital, which revealed she had a serious infection.
She was administered antibiotics and given an urgent chest X-ray, which showed she had pneumonia that had caused a “complete whiteout” of her left lung.
Doctors called the Nets team just after 6.10am to take Pippa to Westmead children’s hospital. A plan was made at 8.30am to put Pippa in an induced coma and intubate her before her chest was drained.
But this didn’t occur immediately because the operating theatre was busy, the inquest heard. Pippa was taken to the intensive care unit instead and intubated about 10am.
Because of shift changes and weather, the Nets team didn’t arrive until 10.10am. Pippa never left Orange – she suffered two cardiac arrests and died just after 1pm.
The inquest has heard this week from the doctor who first examined Pippa at Cowra hospital, Dr Suheil Mir, as well as the two paediatricians who were in charge of her care at Orange hospital, Prof Adam Buckmaster and Dr Christopher Morris.
All of the doctors believed Pippa had a viral respiratory illness when she presented at the Cowra emergency department and when she arrived at Orange hospital later that night.
When she first got to Cowra hospital, her heart rate was observed to be in the “red zone” for sepsis risk. Mir said her heart rate had come back down by the time he examined her about five hours later.
The inquest heard her heart rate had escalated again when she was leaving Cowra and was in the “yellow zone” along with her oxygen levels when she was assessed in Orange.
Appearing before the inquest for a second day of evidence on Thursday, Mir disputed Annah’s claim that he did not auscultate Pippa’s chest and back with a stethoscope when he assessed her in the evening of 12 June.
Barrister Richard O’Keefe SC, representing Pippa’s parents, put to Mir that Annah had told him she was “worried about Pippa’s breathing”.
Mir said: “Honestly, I don’t recall any of that”.
The inquest will resume in May next year, with nurses from Cowra and Orange and several medical experts among the witnesses due to give evidence.