The opportunity to potentially save a five-year-old girl with life-threatening asthma was missed after she was turned away from an emergency appointment because she was late, a coroner has ruled.
Ellie-May Clark arrived at the Grange Clinic in Newport, South Wales, five minutes after her emergency appointment at 5pm on January 26 2015, an inquest heard.
Newport Coroner's Court heard her mother Shanice Clark, who had an eight-week-old baby and did not have a car at the time, was given just 25 minutes to get Ellie-May to the surgery on time.
Miss Clark told the surgery she would be later but when she arrived with Ellie-May, who was wheezing and had been unable to walk, Dr Joanne Rowe refused to see the girl.
The inquest was told that Dr Rowe had a "10-minute rule" where patients who were more than 10 minutes late for appointments were turned away.
Ellie-May collapsed at home at 10.30pm and died in hospital, with a pathologist later finding that her death had been caused by bronchial asthma.
A letter sent by her consultant to the Grange Clinic - received by Dr Rowe - months before her death warned she was at risk of "an episode of severe/life-threatening asthma".
Wendy James, senior coroner for Gwent, recorded a narrative conclusion and said it was "not acceptable" for Ellie-May to have been turned away from her emergency appointment without any clinical assessment or advice for what to do if her condition worsened.
"From the evidence before me, it is not possible for me to determine with certainty whether an earlier intervention would have altered the outcome for Ellie but nonetheless Ellie should have been seen by a GP that day and she was let down by the failures in the system," she said.
"Ellie-May Clark died of natural causes where the opportunity to provide potentially life-saving treatment was missed."
The coroner said she would write to the surgery, the Aneurin Bevan health board, the health inspectorate of Wales, the chief coroner and Miss Clark to prevent future deaths.
Ellie-May's family had asked the coroner to find neglect in her case but Mrs James said there was no evidence to prove the failings caused or contributed to her death.
The girl suffered a wheezy chest from a young age and was first admitted to hospital in November 2011, two months before her second birthday.
She was prescribed inhalers but was admitted to hospital five times between February 2013 and March 2014. In May 2014, her hospital consultant wrote the letter to her surgery to highlight her "life-threatening condition".
"Ellie-May has previously had severe exacerbations of asthma requiring admission to the high dependency unit," it said.
"This places her at risk of having another episode of severe/life-threatening asthma."
Dr Rowe did not place this prominently on Ellie-May's medical records. Ellie-May continued to attend the surgery regularly for treatment for her asthma, including steroids.
Miss Clark kept Ellie-May off school in the week before her death and she was taken on January 22 to see a doctor who said her condition did not require steroids.
On January 26, Ellie-May's school phoned at 1.30pm reporting that she had required her inhaler. When Miss Clark collected her at 3pm, a teacher advised her to take Ellie-May to a doctor.
"During the short walk from school, Ellie was crying, asking for her pink medication (steroids) and asking to be taken to the doctor," Mrs James said.
"Ellie asked her mother to carry her because she couldn't walk."
Miss Clark phoned the surgery at 3.30pm reporting that her daughter was wheezing and could not walk but was not phoned back until 4.35pm, when she was offered the 5pm appointment.
After arriving at the surgery, Ellie-May and her mother waited for a receptionist to finish a phone call and deal with a patient in front of them in the queue. They spoke to receptionist Ann Jones between 5.10pm and 5.18pm.
Mrs Jones phoned Dr Rowe saying Ellie-May had arrived for her emergency appointment.
"Dr Rowe replied that she wouldn't see Ellie as she was late and she would need to come back the following day," Mrs James said.
Neither Mrs James nor Dr Rowe asked why Ellie-May was late or the reason for her emergency appointment. The doctor did not open Ellie-May's clinical notes or ask a colleague to see her.
Miss Clark said Ellie-May was upset after leaving the surgery and asked: "Why won't the doctor see me?"
She told the inquest she did not believe her daughter needed to go to hospital, adding: "Obviously now I would do things differently."
They returned to the family home in Malpas, Newport, where Ellie-May went to bed at about 8pm.
Miss Clark checked on her daughter every 10-15 minutes and went in at 10.30pm after hearing her coughing.
She immediately called 999 after seeing that Ellie-May's face and hands had turned blue and she girl was taken to the Royal Gwent Hospital, where she was pronounced dead a short time later.
A post-mortem examination by Andrew Bamber found Ellie-May had died from bronchial asthma and may have suffered a seizure before her death due to a lack of oxygen.
At the conclusion of the inquest, a statement from Dr Rowe read: "Dr Rowe knows that nothing can be said to Ellie-May's family to make a difference but she would like to say how truly sorry she is."
Justin Chisnall, of Harding Evans Solicitors, read a statement from Ellie-May's family saying they were "disappointed" the coroner did not find neglect in her case.
"The family acknowledge the apology from Dr Rowe, especially as they have been waiting in excess of three years for an outcome and to receive answers to their questions," he said.