Pippa Mae White died of sepsis in June 2022, weeks before her third birthday, and findings from a coronial inquest into her death were delivered on Tuesday.
Deputy State Coroner Joan Baptie found Pippa's death was "wholly preventable" due to a failure to recognise signs of sepsis by two hospitals and communication breakdowns.
The coroner had special praise for Pippa's mum Annah and the videos she took of her daughter throughout her deterioration.
Without those videos, experts would likely have reached a different conclusion about the circumstances of Pippa's death, Judge Baptie said.
Pippa died after being transferred from her hometown of Cowra to Orange Hospital in the NSW central west.
Ms White took multiple videos of her daughter throughout the 20-hour ordeal from her first appearance at hospital to her death.
When asked why she took the videos, Ms White said her motherly intuition took over.
"My family will say I'm a chronic oversharer, which I am," she told reporters outside the NSW Coroners Court.
"But I just knew something wasn't right, I know my children."
Judge Baptie recommended the state's Clinical Excellence Commission use videos Ms White recorded to create training modules for junior doctors to identify sepsis.
"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."
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.
Further delays to her treatment occurred before she suffered two cardiac arrests and died about 12.30pm on June 13.
Ms White has dedicated much of her life since losing her beloved daughter to trying to reform the state's health system, particularly emphasising the importance of parental advocacy.
"It just highlights trust your gut," she said.
"If you're a parent, advocate for your child when they're sick."
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 such as 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 will begin on Monday.
The statewide Raise It helpline was officially rolled out in NSW hospitals in March.
Judge Baptie recommended research into whether technology such as mobile phones should be used to document a patient's condition over time.
The Western NSW Local Health District objected to that out of concern for data protection and patient privacy.
New policies for the proper sharing of notes between hospitals when a patient is transferred were also recommended by Judge Baptie.
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.
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