Senior medical experts say the death of septic shock in a two-year-old girl at a NSW hospital in New South Wales is preventable.

Pippa Mae White died on June 13, 2022, two months before her third birthday, doctors at the hospital in Cowra and Orange mistakenly believed she had an acute viral disease rather than a serious bacterial infection that killed her.

He was not involved in a "expert meeting" of Pippa treatment while investigating her death in the Royal Colony on Wednesday, and he said she should be tested and treated for potential sepsis.

NSW Lieutenant Coroner Joan Baptie is studying whether Pippa’s death is preventable and whether she has received proper care in Cowra and Orange as well as in the neonatal and pediatric emergency transport services teams.

Previous investigations have heard that Pippa appeared at Cowra Hospital around 2pm on June 12, 2022, with a fever, vomiting and a heart rate of 171 times a minute, which is considered septic in the "red area".

After she was transferred to Orange, she did not have a blood test until 4 a.m. on June 13, indicating she had a serious infection.

She was taken antibiotics and was given a chest X-ray, which showed she had pneumonia, causing "complete white water" in her left lung. She suffered two cardiac arrests and died after 1 p.m.

Five of the seven medical experts submitted joint reports in the investigation and provided verbal evidence on Wednesday: Professor Simon Craig, Professor John Raftos, Professor Warwick Butt, Professor Adam Irwin and associate Phillip Braslins, and GP Robert Morton.

Although there is a difference in when the pediatric sepsis pathways that should activate PIPPA, all doctors agree that the investigation of possible sepsis, including blood tests, should be much earlier than before.

Experts believe that medical staff are "anchored" in the wrong diagnosis of viral diseases. They stressed the importance of "sequence observation" that makes vital signs heart rate and oxygen saturation more frequently than in PIPPA.

A video of PIPPA was previously shown in the koala emergency room, making a "gurgling" noise while breathing, which doctors said Wednesday could be identified by a stethoscope.

Raftos said that when Pippa was brought to Cowra, she was already a "very sick" and "drowsy" child and needed a quick response.

He said that if Kura’s medical staff were not able to treat Pippa immediately, as they heard before inquiry, they should have arranged an ambulance to take her to Orange, or have her mother, Annah, take her there.

Another option, Raftos said, is to "do nothing, that's what they do."

Craig said when Pippa was "seriously ill" at 1 a.m. on June 13, the "practice or breaking" point of "things become absolutely wrong" was the "upgrade" at the Orange Hospital.

Dr. Christopher Morris, a junior physician in charge of taking care of Pippa in Orange, cried in a witness box last year, providing evidence to the investigation and saying he hoped he would respond quickly earlier that night.

Experts said on Wednesday that night Professor Adam Buckmaster should have evaluated her that night. I heard before asking that he didn't go to the hospital until the morning of June 13.

Most experts agree that Pippa should have her blood tested and receive antibiotic treatment around 9 p.m. on June 12 after arriving at the hospital.

"She should go (sepsis route), she should be intravenous (intravenous), she should do the blood, she should be given antibiotics. I think that's clear," Bart said.

"I believe death is preventable, which means the system failed her," Bart said.

The investigation continues, with a hearing expected later this year.