A western NSW health executive has told an inquest that his hospitals are still not consulting a sepsis diagnostic guide enough after a toddler died of the condition almost three years ago. Two-year-old Pippa Mae White died from the disease, and pneumonia, at Orange Hospital in central west NSW in June 2022. She initially presented at Cowra Hospital before being transferred later that night to the health facility in Orange. The inquest into her death previously heard her high heart rate alone at both facilities was considered in the "red zone" for a child likely infected with sepsis and required a rapid response, according to a NSW Health policy document. A rapid response triggers senior doctors to quickly attend and assess a patient, which was not activated at either hospital. The nurse at Cowra said she was aware of the paediatric sepsis pathway document but did not use it, while the nurse at Orange said she had never seen it. Executive director of quality, clinical safety and nursing at the Western NSW Local Health District (WNSWLHD), Adrian Fahy, gave evidence at the inquest on Tuesday. He said he was "concerned" the document was not used in Pippa White's care. "It's indeed quite remarkable," he told the inquest. "Sepsis training has been quite prevalent across NSW Health for a number of years." He said the WNSWLHD made optional training on detecting the condition mandatory since the young girl's death and has so far delivered 75 virtual sessions on the topic. The inquest heard hospitals across the district audited how often the sepsis pathway document was used in the care of patients who were diagnosed with the condition. Mr Fahy said despite an increasing trend, the hospitals were not using it in all cases. "What I think needs to happen is there needs to be a much stronger emphasis. "[And] where needed, having some difficult conversations around 'why wasn't a pathway included?'" Mr Fahy also gave evidence that the district made several changes to improve care since Pippa White died. He said an alert tool was being developed which would send a prompt to clinicians if the vital signs they are logging on the electronic medical record could indicate sepsis. The concern of a parent or carer will also be included in the new paediatric observation chart due to be released next month. If it was the latter it would trigger an additional "yellow zone" criteria which could result in a clinical review within 30 minutes. The inquest heard Pippa White's mother, Annah White, attempted to activate the REACH initiative (recognise, engage, act, call, help) during her daughter's care without success. The system allowed family members or parents to escalate their concerns with hospital staff about the patient's condition, and prompt a review, which should occur within half an hour. Mr Fahy said the WNSWLHD had tried to make the initiative more obvious, such as clearly including it in local emergency response procedures. Hospitals had also put up posters about the initiative with a phone number and a QR code with a video that explained the process. The inquest continues on Wednesday.