A nurse has denied advising a child’s family to wait at home due to hospital overcrowding, just one day before the two-year-old died from sepsis, an inquest has heard.
Pippa Mae White was experiencing vomiting and diarrhoea when she was taken to Cowra Hospital in central west NSW on June 12, 2022.
During the inquest into her death, it was revealed that registered nurse Nikota Potter-Bancroft assessed Pippa and recorded a heart rate of 171 beats per minute—a reading that falls into the ‘red zone’ under NSW Health’s paediatric sepsis guidelines, indicating the need for an urgent medical response.
Pippa’s family hopes the tragedy will lead to reforms in the state’s healthcare system.
Ms Potter-Bancroft testified that the emergency department was full at the time, and she was informing patients about potential long waits. However, the child’s mother, Annah White, told the inquest the nurse had recommended waiting at home instead.
The nurse denied ever making that suggestion.
“Annah mentioned she wasn’t keen on staying in the waiting room because Pippa was miserable,” Ms Potter-Bancroft said. “I told her it was her choice where she waited and that if she chose to leave, I’d call her when it was their turn.”
She also noted that the hospital was preparing to receive a critically ill 8-year-old arriving by ambulance.
Later that afternoon, Ms White brought her daughter back to the hospital, and they were eventually transferred to Orange Hospital that evening.
Nurse did not suspect sepsis
Ms Potter-Bancroft said she didn’t believe Pippa was showing signs of sepsis and, even in hindsight, stood by that assessment. She attributed the elevated heart rate to the child being distressed rather than critically ill.
“There wasn’t much I could do to confirm that, but I discussed it with a doctor and wanted to try some treatment to see if it made a difference.”
Pippa was given ondansetron, a medication for nausea and vomiting, in hopes of reducing her heart rate.
Although Ms Potter-Bancroft was familiar with the paediatric sepsis protocol, she admitted she hadn’t used it at Cowra Hospital and did not consider Pippa’s condition to meet the criteria for sepsis despite acknowledging her heart rate alone warranted urgent action.
In her triage notes, she described the child as “miserable and lethargic” but maintained she did not believe the toddler was septic.
“I’ve seen kids who are visibly very sick—they’re floppy, have to be carried. Pippa was clearly tired but alert and conscious,” she said.
Condition worsened
The inquest also heard that Pippa’s condition deteriorated overnight at Orange Hospital.
Former paediatric nurse Roslyn Sadler said the child’s breathing was abnormal upon arrival. She monitored Pippa’s vital signs three times overnight, recording a heart rate of 196 bpm at 2:35am.
Ms Sadler testified that she contacted the doctor several times with concerns about the child’s condition. She acknowledged that, looking back, she should have initiated a rapid response.
“We should have escalated things sooner,” she said.
Pippa passed away later that day from sepsis and pneumonia.
Push for change
Pippa’s mother, Annah White, told the inquest she believes systemic issues in the healthcare system led to her daughter’s death and expressed hope for meaningful reform.
“What will it take for parents to be listened to and for protocols to be followed?” she said.
“Pippa, I see where you should be in every part of my life. In everything I do, there’s a space that should have been filled by you.”
Outside the courtroom, Ms White advocated for the introduction of “Pip’s Law”—a proposed policy that would empower families to raise concerns more effectively with clinicians. She also called for mandatory paediatric sepsis training for all healthcare workers, particularly in rural and regional settings.
The inquest will resume on Tuesday.
