A judge has ruled that a two-year-old girl should never have died, describing her death as “wholly preventable” after multiple hospital failures.

Pippa Mae White died in 2022 after suffering two cardiac arrests, with a court hearing on Tuesday that doctors and nurses at Cowra and Orange hospitals failed to diagnose her deteriorating condition despite showing symptoms of sepsis.

WATCH THE VIDEO ABOVE: Toddler’s preventable death prompts hospital reforms

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The inquest heard audible grunts from the little girl gasping for air were in fact a glaring sign that something was seriously wrong.

“I think the evidence today and over the whole inquest is pretty damning,” Pippa’s mother Annah White said.

“One thing that Pippa’s case proved is like parental concern is totally ignored.”

Two-year-old Pippa Mae White died in 2022 after suffering two cardiac arrests. Credit: 7NEWS

The court heard life-saving treatment was delayed due to insufficient regional health resources, inadequate assessments by medical staff and a series of communication breakdowns.

There were multiple missed opportunities to save the little girl’s life.

The court has recommended mobile video calls now be used to update senior clinicians on patients’ conditions, with the videos set to train future doctors so this doesn’t happen again.

The judge commended Pippa’s mother for capturing videos of her daughter’s condition, describing them as invaluable and saying without them it is highly likely the inquest would have come to different conclusions.

“I just felt like I really needed to capture what was happening,” Annah said.

“She won’t just be a sad story, I keep saying it, but change will happen, it’s already happening.”