‘She would have survived’: The three key moments that led to tragedy

The verdict was unanimous. One by one, the medical experts called to provide evidence at the inquest into two-year-old Pippa White’s death confirmed what her family had long suspected: her life could have been saved.

“This is a tragedy that was avoidable,” said Associate Professor Warwick Butt, a renowned intensive care consultant at Melbourne’s Royal Children’s Hospital. “If the trajectory of her illness had been recognised [earlier] … she would have survived.”

Hearing those words on Wednesday in the front row of the courtroom, Annah White felt a weight lifted from her shoulders.

“I feel so bloody validated,” White said outside court. “Now that I am supported by world-leading medical experts who confirm that Pip could have survived … we can begin to focus on the bigger question: why did NSW Health fail us, and how do we stop this from ever happening again?”

Pippa White with her mother Annah.

Pippa Mae White died on June 13, 2022, at Orange Base Hospital, less than 24 hours after she recorded a heart rate in the “red zone” for potential sepsis.

Sepsis occurs when the body’s immune response to an infection causes damage to its own organs and tissues, but the condition wasn’t raised as a possible cause of her rapidly declining health until 4am, more than 12 hours after Pippa was first triaged.

Although there was some disagreement as to when doctors should have escalated their treatment of Pippa, all five experts called on Wednesday agreed that the “sepsis pathway” – a standard guide for recognising and treating the potentially deadly condition – should have been activated much sooner.

Over three harrowing days, lawyers and expert witnesses painstakingly reconstructed the hours leading up to Pippa’s death, and how the system failed to pick up on her rapidly declining condition, and the increasing concerns of her parents. Here are those key moments.

June 12, 2022, around 2pm: Pippa arrives at Cowra Hospital

Annah White takes her daughter to the emergency department at Cowra Hospital on a brisk Sunday afternoon. For the previous four days, the toddler had struggled to shake off a runny nose, fevers and a cough (the medical experts agreed that she was probably struggling with a rare and aggressive group A streptococcus infection). Pippa’s symptoms grew to include diarrhoea and vomiting, she took her two-year-old to the hospital a few hundred metres down the road.

It had already been a busy day at the small rural emergency department. All four beds were full, including one with a patient who had required a medical cardioversion (an alternative to defibrillation) to restore normal heart rhythm, and an agitated parent who had earlier been removed by police.

To make matters worse, an ambulance was on its way carrying an eight-year-old already receiving resuscitation.

Potter-Bancroft told the inquest she had been working since 7am and had not had a break by the time she completed Pippa’s triage at 2.06pm. “It was a hectic day,” she said.

The nurse described Pippa as “miserable and lethargic” and recorded her heart rate at 171 beats per minute – high enough to be considered in the “red zone” for sepsis risk.

Potter-Bancroft triaged Pippa as a category 3 patient, meaning she had a “potentially life-threatening condition” that needed treatment within 30 minutes. But in a video taken at 2.19pm and shown to the court, Pippa showed difficulty breathing and was “grunting”, something the experts agreed should have classified her as an urgent patient needing treatment within 10 minutes.

This was the first opportunity to recognise sepsis, they said. It was not the last.

Parents worried their child is getting sicker can:

1. Put their hands up and tell staff right away.

2. If they are still worried, ask the nurse in charge to look at their child.

3. If they believe something is still not right and want to see a doctor they should ask for a “clinical review”, which should be carried out within 30 minutes.

4. Parents who are still not satisfied with the level of care can trigger a “rapid emergency response” by calling a unique number, displayed in REACH brochures inside hospitals. Doctors should arrive within minutes to reassess the child’s condition.

White said she took her daughter home after staff told her the hospital was too busy, but returned a short time later. She asked for the REACH (Recognise, Engage, Act, Call, Help is on its way) number. This should have raised alarm bells, Butt said.

“An experienced mother is now very worried … [that is] a very important sign.”

Associate Professor Adam Irwin, an expert in paediatric infectious diseases at the University of Queensland, said doctors were “anchored” on Pippa’s diagnosis being caused by a viral infection, and this continued after she arrived at Orange around 9.20pm.

Dr Adam Buckmaster, a locum paediatrician, instructed staff that if Pippa had not improved by 1am, they would need to give her fluids and escalate her treatment. “For the life of me, I don’t understand why they didn’t follow their plan,” Butt said.

June 13, 2022, around 1am: Pippa continues to decline

Medical notes from around midnight suggested Pippa was “settling”, but by 1am, it was clear she was seriously unwell.

“We’ve got failing to improve and getting worse … all the more reason to get the blood [tests] in, get her on a drip and commence treatment,” said Professor Simon Craig, a paediatric emergency medicine specialist at Monash Medical Centre in Melbourne.

A video taken by White at 2.19am showed Pippa grunting and struggling to breathe.

At 2.35am, her heart rate was 196 beats per minute. This, the experts said, was the “make or break” moment when things “went absolutely wrong”. (they acknowledged the fact that Dr Christopher Morris, the on-call registrar, had already worked a full 12-hour shift during the day).

“The deterioration that was occurring could almost only be attributed to sepsis … there was no point calling for blood tests,” Irwin said.

A blood test was taken at 4am – the first time the word sepsis appeared in Pippa’s medical notes. “Not until far too late did [anyone] question the diagnosis they reached,” said Irwin.

June 13, 2022, around 6am: “Go now”

Even after these missed opportunities, Butt told the inquest one word could have given Pippa one last fighting chance: “Now.”

By 6am, Pippa’s doctors knew she was gravely ill and at risk of septic shock, but the experts agreed their reaction lacked urgency. Craig told the inquest Pippa should have been moved to somewhere she could be resuscitated. “A general ward isn’t a great place to run a resuscitation … and Pippa needed resuscitation,” he said.

At 6.10am, Pippa’s doctors called the NSW Newborn and paediatric Emergency Transport Service (NETS) advice line. A specialist doctor advised them on treatment while pilots assessed whether they could fly. A helicopter was immediately ruled out – Orange in June was too icy. An aeroplane could fly, but couldn’t leave until the fog lifted around 9am.

There were people in the hospital with intensive care skills, Craig said, but they “didn’t come to the bedside” because nobody called a rapid response. In Victoria, where both Craig and Butt practice, Pippa would have met “go now” criteria requiring all hands on deck.

The NETS team arrived, but Pippa never left Orange. Around 1pm, she suffered two cardiac arrests. The second was fatal.

Six experts agreed that, if Pippa had been put on the sepsis pathway at any of these moments, it “would probably have prevented her death”.

Her parents’ worries were “entirely appropriate”, the experts said, and “should have raised everyone’s concerns”.

After Joe Massa’s death in September, Health Minister Ryan Park vowed to overhaul the REACH protocols to make it easier for parents and carers to raise concerns about the condition of their loved ones in hospital.

Outside court, White said she hoped to use her experience to push for change and help other parents who find themselves in a similar position.

“It’s already such a frightening and vulnerable moment when you take your sick child to hospital. But it becomes even harder when health staff don’t take your concerns seriously,” she said. “Keep asking questions. Don’t let them ignore you like they ignored me.”

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