Two-year-old’s death in hospital from sepsis was ‘completely preventable’, grieving parents tell NSW inquiry

The parents of a two-year-old girl who died of septic shock after being misdiagnosed by doctors in regional New South Wales believe her death was “completely preventable”, an inquest has heard.

Pippa Mae White died on June 13, 2022, two months before her third birthday, after doctors at hospitals in Cowra and Orange believed she had an acute viral illness, rather than the bacterial infection that led to her death.

New South Wales Deputy Coroner Joan Baptie is investigating whether Pippa’s death could have been prevented 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, while her husband and Pippa’s father, Brock, sat next to her.

“We personally believe that Pip’s death was completely preventable. We will never be a complete family again,” Annah said.

“We as your parents promise to fight the rest of our lives to prevent this from ever happening again… Your deaths will not be in vain.”

Annah described her daughter as “the most perfect angel in the world” and said that even at such a young age she was compassionate, empathetic and sensitive.

During the inquest, a 25-minute montage of photos and videos was shown of Pippa’s short life, as she played with her twin brother Leo and her older siblings Lucy, Tamika, Sophie and Bodhi and their parents and grandparents.

A quilt made from Pippa’s clothes was draped over the witness box at the coroner’s inquest in Lidcombe. A photograph of the young girl running through a field of flowers was displayed alongside it.

Her family and friends, dressed in her favorite color, 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 at approximately 2pm on June 12, 2022, with fever, vomiting and an elevated heart rate, the inquest found.

It wasn’t until 4am on 13 June, more than eight hours after she was transferred to the Orange hospital, that blood was taken. It showed that she had a serious infection.

She was given antibiotics and had an emergency chest x-ray, which revealed she had pneumonia, which had completely destroyed her left lung.

Doctors called the Nets team just after 6.10am to take Pippa to Westmead Children’s Hospital. At 8.30am a plan was made to put Pippa into an induced coma and intubate her before her chest was drained.

But this did not happen straight away because the operating theatre was busy, the inquest heard. Pippa was instead taken to intensive care and intubated at around 10am.

Due to shift changes and the weather, the Nets team didn’t arrive until 10:10am. Pippa never left Orange – she suffered two cardiac arrests and died just after 1pm.

This week, the doctors who first examined Pippa at Cowra Hospital, Dr Suheil Mir, were interviewed. Also interviewed were the two paediatricians responsible for her treatment at Orange Hospital, Prof Adam Buckmaster and Dr Christopher Morris.

All doctors were convinced that Pippa had a viral respiratory infection when she presented to Cowra A&E and arrived at Orange Hospital later that evening.

When she first arrived at Cowra Hospital, her heart rate was noted to be in the “red zone” for sepsis risk. Mir said her heart rate had dropped again when he examined her about five hours later.

The investigation found that her heart rate had increased again when she left Cowra and she was in the ‘yellow zone’, as were her oxygen levels when she was assessed as being in the orange zone.

Mir appeared for the second day of the inquest on Thursday and disputed Annah’s claim that he did not examine Pippa’s chest and back with a stethoscope when he examined her on the evening of June 12.

Barrister Richard O’Keefe SC, representing Pippa’s parents, told Mir that Annah had told him she was “concerned about Pippa’s breathing”.

Mir said: “To be honest, I can’t remember anything about that.”

The inquiry will resume in May next year, with witnesses including nurses from Cowra and Orange and several medical experts.