The inquest into the tragic death of two-year-old Pippa Mae White has revealed appalling inadequacies in the sepsis protocol at Orange Hospital. These failures have led to serious concerns regarding patient safety across central west New South Wales. Pippa sadly passed away from sepsis and pneumonia in June 2022. Her death prompted a complete review of the hospital’s adherence to any processes outlined by nationally accepted guidelines for diagnosing and treating sepsis.
Pippa White’s mother, Annah White, attempted to invoke the REACH initiative during her daughter’s illness, a program designed to empower family members to escalate concerns about a patient’s deteriorating condition. Her experience with this unfortunate assignment failure turned tragic, underscoring possible breakdowns in communication and response in the hospital environment.
The REACH Initiative and Its Limitations
Through the REACH initiative, parents and other family members are empowered to notify hospital staff that a patient’s condition is concerning. This forces staff to re-evaluate the area in 30 minutes. Unfortunately, Annah White’s experience shows that this important initiative was poorly executed in her daughter’s situation.
Adrian Fahy is the executive director of quality, clinical safety and nursing in the Western NSW Local Health District (WNSWLHD). That’s why he took the stand at the inquest—to impart his insights. Mr Fitzgibbon acknowledged the work done by WNSWLHD to promote awareness of the REACH program. They got creative by really weaving it into the local emergency response playbook. Despite these efforts, the results were unsatisfactory.
“It isn’t exactly what I would like to see,” – Mr Fahy
There are limitations to the REACH initiative. These failings reflect a larger issue at play, in which hospital staff were ill prepared to address parent complaints correctly. The inquest goes further to ask how well trained are the hospitals in how to use the resources at their disposal.
Shortcomings in Sepsis Protocols
Shortly thereafter, the inquest uncovered that a sepsis diagnostic protocol existed. It was not used effectively throughout Pippa White’s treatment journey. When surveyed, a nurse at Cowra admitted that she was aware of but had not seen the pediatric sepsis pathway document. That’s not what she used to treat Pippa. In the same vein, an Orange-based nurse reported that she had never laid eyes on this key file.
Adrian Fahy tweeted his frustration at a breach in protocol, not following clearly established sepsis protocols during Pippa’s treatment. “A specific question will be asked around ‘do you feel your child is improving or deteriorating?’” he stated, emphasizing the need for more proactive engagement between healthcare providers and parents.
The WNSWLHD has lost no time in taking action to rectify these problems. They have made training on detecting sepsis mandatory for staff, conducting 75 virtual sessions on the topic following Pippa’s death. These changes will increase staff awareness about what is going on. Then they’ll have the skills to identify and act on warning signs of sepsis and save lives.
Future Improvements in Patient Care
The awful circumstances leading to Pippa White’s death have led to positive change. The WNSWLHD is currently making these system-level changes to better deliver pediatric care. Annah White’s background as a parent will be an invaluable resource in developing the new pediatric observation chart. This new chart will be coming out next month, so stay tuned! This significant advancement is an encouraging sign that legislators are learning from their costly mistakes and working to help ensure future patients aren’t harmed.
The inquest into Pippa White’s death continues as investigators examine the circumstances leading up to her passing and assess the hospital’s response. What we have found so far highlights shocking breaches in protocol that would have likely changed the outcome for Pippa.
