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Judge Rules Four-Year-Old Girl's Hospital Death Was 'Wholly Preventable', Recommendations Made
Judge Joan Baptie said clinicians missed sepsis warning signs and failed to escalate care, and she recommended policy changes and junior doctor training.
On Tuesday, Deputy State Coroner Judge Joan Baptie ruled the 2022 death of four-year-old Pippa White at Orange Hospital was "wholly preventable" following a coronial inquest.
Pippa presented to Cowra Hospital with sepsis symptoms, but nurse Nikota Potter-Bancroft failed to place her on the paediatric sepsis pathway; Dr. Suheil Mir's assessment was deemed "not adequate."
Dr. Morris diagnosed sepsis at Orange but failed to contact Prof Adam Buckmaster, provide antibiotics, or order timely blood tests. Judge Baptie found Morris missed a critical grunt Pippa exhibited 16 minutes after a video recording.
Judge Baptie issued three recommendations, including policy amendments for patient observations and remote specialist reviews, despite opposition from the Western NSW Local Health District.
Training initiatives for junior doctors based on Pippa's case and hospital videos require approval from her mother, Annah White, and the Clinical Excellence Commission.