Trigger warning: This article mentions children’s death as we provide an update on Pippa Mae’s Coronial Inquest.
In June 2022, 2-year-old Pippa Mae White was taken to hospital by her concerned parents after she started vomiting and had an elevated heart rate.
The next day, two months before her third birthday, little Pippa died.
This week launched the beginning of Pippa Mae White coronial inquest, to determine the circumstances of her death and if it was avoidable.
Was Pippa’s Death Avoidable?
Pippa’s Parents Speak Out
In a statement at the inquest, Pippa’s mother Annah read a statement saying, “It is our personal opinion that Pip’s death was totally avoidable. We will never be whole as a family again.”
She described her daughter as a perfect angel and that even at her young age, she was empathetic, sensitive, and compassionate.
“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,” she added.
Remembering Pippa
A 25-minute montage of Pippa’s short life was shown at the inquest of Pippa with her parents and grandparents, older siblings Lucy, Tamika, Sophie and Bodhi, and playing with her twin brother Leo.
Draped over the stand was a quilt made from her clothes with a picture capturing her spirit beside it; Pippa running through a field of yellow flowers in a yellow sundress, surrounded by butterflies. A sea of yellow filled the room as Pippa’s family and friends dressed in her favourite colour and openly wept while the video played. The final images were of Pippa in her coffin and Lucy and Leo visiting her grave.
What Happened To Pippa?
At approximately 2pm on June 12, 2022, Pippa presented to Cowra hospital. She did not have a blood test until 10 hours later at 4am on June 13, 2022, hours later after she had been transferred to Orange Hospital. An urgent X-ray determined Pippa had pneumonia, which had caused a complete whiteout of her left lung. She was administered antibiotics.
Newborn and Paediatric Emergency Transport Service (NETS) team were called at 6.10am to transfer Pippa to Westmead Children’s Hospital. At 8.30am they planned to put Pippa into an induced coma and intubate her before her chest was drained.
With the operating theatre busy, this didn’t happen on time and NETS didn’t arrive until after 10am due to weather and shift changes. Tragically, Pippa was never transferred to Westmead. The 2 year old toddler suffered two cardiac arrests and passed away just after 1pm, less than 24 hours after she was admitted, and two months before she and Leo would turn three.
Pippa Mae White Coronial Inquest Hears From Medical Staff
The inquest heard from Dr Suheil Mir, who first examined Pippa in Cowra, and Prof Adam Buckmaster, and Dr Christopher Morris who were in charge of her care in Orange.
After being asked if he told Annah to take Pippa home, Mir stated he would never tell patients to leave, and that the hospital was devastated by Pippa’s death.
Morris told the inquest it was an oversight not to call rapid response. He admitted this error in judgement happened because he wanted to do his due diligence and have as much information as possible to give to his superiors.
“I didn’t feel like I’d closed my mind to this only being one thing,” he said. “I didn’t feel anchored but clearly I made an error of judgment. If I’d have my time over, sure, I’d do anything to make some different decisions,” he added, struggling to speak over his emotions.
During Morris’s questioning, the Lidcombe Coroners Court watched a video of Pippa grunting, a medical term for the body forcing air from the lungs. Her head rested on her mother’s shoulder.
During questioning, Morris confirmed he could have been fatigued. He’d worked a full shift and was on call when Pippa was brought in. Since Pippa’s death, rostering at Orange hospital has undergone changes. Morris inferred this was a result of this tragic day.
Mir said he was concerned but didn’t think the paediatric sepsis pathway applied to her.
“It didn’t meet the criteria for sepsis, but I thought there was a possibility that it could be sepsis which is why I called the specialist [Buckmaster],” he said. “We can’t give every kid antibiotics.”
Buckmaster arranged for her to be transported to the larger hospital after believing Pippa had a viral illness and dehydration.
When Pippa was picked up for transport, her temperature was 38°C, and her pulse a rapid 169 beats per minute.
“If that information had been relayed to me, that definitely would have led me to take blood tests, and start antibiotics,” Mir said.
Despite receiving a phone call at 4.15am, Buckmaster did not arrive until hours later. He said, in hindsight, he regrets not attending in person after the 4.15am phone call.
“I can rightly see people would be critical I didn’t jump out of bed at that time,” Buckmaster said. “In retrospect, I wish I had.”
Dr Buckmaster believed Pippa’s condition did not start to significantly deteriorate until around midnight after she was admitted to Orange Hospital, and by that time, it would have been too late for antibiotics.
He said if Pippa had been given antibiotics 12 or 18 hours earlier it may have made a difference to the outcome.
“She died from cardiovascular collapse, overwhelming sepsis,” he said. “It’s really hard for people to hear this – some of that we can’t control.”
“I wish with all my heart that we had a different outcome,” an emotional Dr Buckmaster said as he apologised to Pippa’s family.
“I hope that this process can bring some answers for you and possibly some changes for the better,” he added.
Still searching for answers…
Pippa’s family hopes they will not only get answers for the death that has shattered them, but the outcome will see changes put in place to prevent this from happening to another family.
The inquest was intending to interview nurses and intensive care staff, however ran out of time so they will be next to take the stand when the inquest continues 26th – 30h May 2025.
“It’s such a long drawn out process … and actually torture … but nothing worse then her death.” Pippa Mae’s mother Annah White
I can’t imagine the trauma this family has endured. Despite my medical emergency with my eldest child, I still have them. My heart goes out to Pippa’s family including her parents, four older siblings, and especially her twin brother, Leo.
RIP precious girl xx
