Pippa Mae White died of sepsis in June 2022, weeks before her third birthday, with findings from a coronial inquest delivered on Tuesday.
Deputy State Coroner Joan Baptie found Pippa's death was "wholly preventable" due to a failure to recognise signs of sepsis across two hospitals, along with communication breakdowns.
Pippa died after being transferred from her hometown of Cowra to Orange Hospital in the NSW central west.
The inquest heard multiple healthcare failures including understaffing, a lack of training and missed opportunities for escalation, Pippa's mother said.
A key concern raised in the inquest was the dismissal of Annah White's warnings her daughter was sicker than treating clinicians thought.
Ms White took multiple videos of her daughter throughout the 20-hour ordeal from her first appearance at hospital to her death.
Without those videos, experts would likely have reached a different conclusion about the circumstances of Pippa's death, Judge Baptie said.
"The videos are striking," the coroner said.
"The videos depict a child that is clearly septic ... (doctors) should have been able to identify Pippa's grunt."
Judge Baptie recommended the state's Clinical Excellence Commission use videos Ms White recorded to create training modules for junior doctors to identify sepsis.
Since Pippa's death, Ms White has been working with the commission to implement a program designed to give more say to concerned families.
The Raise It campaign allows parents and carers who feel the condition of their loved one is being overlooked to ring a helpline and seek guidance from a senior health worker.
The impetus for Raise It came from stories like Pippa's and the high-profile case of two-year-old Joe Massa, who died of a cardiac arrest at Northern Beaches Hospital in September 2024.
A week-long inquest into the circumstances leading up to Joe's death is set to begin on Monday.
Raise It was officially rolled out in NSW hospitals in March.
The coroner heard Ms White took Pippa to hospital in Cowra on June 12, about three days after she began experiencing a high temperature, vomiting and diarrhoea.
The girl was eventually transferred to Orange, where an experienced pediatrician read notes from a doctor at Cowra and formed the view she was getting better.
But Ms White testified that at the time her daughter was "lethargic" and vomiting fluids given to her.
At Orange Base Hospital, tests revealed the toddler had pneumonia with a complete white-out of her left lung.
Further delays occurred before she suffered two cardiac arrests and died about 12.30pm on June 13.
The information breakdown between the junior doctor at Cowra and the treating doctors and nurses in Orange was one of the reasons Pippa's condition was not spotted straight away, the coroner said.
New guidelines for the proper sharing of notes between hospitals when a patient is transferred were recommended by Judge Baptie.
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