All four beds were full, including one with a patient who had required a medical cardioversion (an alternative to defibrillation) to restore normal heart rhythm, and an agitated parent who had earlier been removed by police.

“It was a hectic day,” Potter-Bancroft said.

Pippa’s mother Annah White earlier told the inquest that Potter-Bancroft advised her to wait for treatment at home because the ED was too busy. The nurse disputed this, saying she explained that there was “another sick kid coming in, [and] there’s going to be a wait”.

Annah went home but returned a short time later when Pippa’s condition deteriorated. She was then transferred to the paediatric ward at Orange Base Hospital.

The court was played a video of Pippa, taken by her mother at 2am, struggling to breathe while hooked up to a number of observational machines on the paediatric ward.

Roslyn Sadler, a nurse on the ward, told the inquest she “made half a dozen or so calls” to Dr Christopher Morris, the registrar on call, before he arrived to take bloods and conduct a further assessment of Pippa.

Asked if a rapid response should have been called as Pippa’s condition deteriorated further, Sadler said: “In hindsight, probably yes.”

Dozens of family members and supporters packed the courtroom at Lidcombe Coroners Court, wearing Pippa’s favourite colour, yellow. Those who did not fit listened to the inquest next door.

Pippa White with parents Annah and Brock, sisters Tamika, Sophie, and Lucy, twin brother Leo, and brother Bodhi.

Earlier in the day, Pippa’s father Brock told the inquest the loss of his daughter had been an unfathomable “nightmare” in a life defined by tragedy.

The loss of his father when he was eight years old, and his mother when he was 17, taught him he could overcome anything, but losing his daughter had left him “a shell of my former self”.

“I wanted a huge family so when I was gone my children would have each other to lean on,” White told the inquest.

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He returned to playing rugby league and union to “show my kids there was a positive way to deal with” the tragedy.

Pippa’s grandmother Marianne Stonestreet, a retired nurse, told the inquest she left Orange Base Hospital the evening before the toddler’s death “sick with worry”.

“I know this should not have happened,” she said. “I will always be Pippa’s Ma and I will always love her with every beat of my broken heart.”

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