A health executive from western NSW has acknowledged at an inquest that hospitals in the region are still not adequately using a diagnostic guide for sepsis, nearly three years after the death of toddler Pippa Mae White from the condition.
Two-year-old Pippa died from sepsis and pneumonia at Orange Hospital in June 2022. She had first presented at Cowra Hospital before being transferred to Orange later that night.
The inquest previously heard that her elevated heart rate at both facilities fell within the “red zone” for a child likely suffering from sepsis, as outlined in a NSW Health policy. This status should have triggered a rapid clinical response, but no such action was taken.
A nurse at Cowra Hospital admitted she was aware of the paediatric sepsis pathway document but didn’t consult it. Meanwhile, a nurse at Orange Hospital said she had never encountered the guide.
Adrian Fahy, Executive Director of Quality, Clinical Safety and Nursing at the Western NSW Local Health District (WNSWLHD), gave evidence on Tuesday. He expressed concern that the sepsis pathway wasn’t used in Pippa’s care.
“It’s quite remarkable,” he said. “Sepsis training has been widespread throughout NSW Health for several years.”
Since Pippa’s death, the WNSWLHD has made previously optional sepsis training mandatory and delivered 75 virtual training sessions on the subject. An audit was also conducted across district hospitals to monitor how often the sepsis guide was used in sepsis diagnoses.
Mr Fahy said usage had improved but was still inconsistent.
“It’s not exactly where I’d like it to be,” he said. “There needs to be much stronger emphasis and, where necessary, frank discussions about why the pathway wasn’t followed.”
He also testified that several reforms had been implemented to improve patient care. These include developing an alert system that would notify clinicians when logged vital signs may indicate sepsis. A revised paediatric observation chart, set to launch next month, will also factor in parental concern.
A new question will ask, “Do you feel your child is improving or deteriorating?” If the response indicates concern, it will activate a new “yellow zone” alert, prompting a clinical review within 30 minutes.
The inquest heard that Pippa’s mother, Annah White, attempted to initiate a clinical review during her daughter’s care by using the REACH initiative (Recognise, Engage, Act, Call, Help), but was unsuccessful. This system is designed to allow family members to escalate concerns and trigger a timely clinical response.
Mr Fahy said efforts had been made to raise awareness of the REACH system, including incorporating it into emergency response protocols and displaying posters with a phone number and a QR code linking to an explanatory video.
The inquest will resume on Wednesday.
