A five-year-old girl with severe asthma died after being turned away from an appointment with an emergency doctor because she was five minutes late, an inquest has been told.

The coroner said the chance to provide Ellie-May Clark with “potentially life-saving treatment” was missed and she had been let down by failings in the system.



Outside court in Newport, south Wales, Ellie-May’s family paid tribute to the “perfect child” and expressed disappointment that a finding of neglect had not been made.

They said: “The coroner found that there had been grave failings in the care provided to Ellie-May. She was let down by the system. We are disappointed that a finding of neglect was not reached as, in our opinion, this was a clear case of obvious neglect.”

Ellie-May Clark arrived at the Grange clinic in Newport five minutes after her emergency appointment, her mother, Shanice Clark, told the inquest on Monday.

She was booked in to see Dr Joanne Rowe, a partner in the surgery and its lead for child safeguarding, at 5pm as the child was wheezing and unable to walk.

Ellie-May and her mother waited to see the receptionist and reached the front of the queue between 5.10 and 5.18pm.

Rowe had a “10-minute rule” where she would not see patients who arrived more than 10 minutes after their appointments and refused to see Ellie-May as she was late, the inquest heard.

Ellie-May asked: “Why won’t the doctor see me?” before returning to the family home in Malpas, Newport, where she went to bed at about 8pm.

Clark heard her daughter coughing at 10.30pm and called an ambulance after finding her struggling to breathe, with her hands and face blue. The girl died shortly after arriving at the Royal Gwent hospital.

The inquest in Newport heard that Rowe had previously received a letter from a consultant stating that the little girl was at risk of having “an episode of severe/life-threatening asthma”.

Rob Sowersby, a lawyer representing Ellie-May’s family, told the inquest: “Dr Rowe made a clinical decision without any clinical information whatsoever. She sent away a five-year-old patient from an emergency appointment without even opening her records.

“Dr Rowe agreed that when she opened the letter from the hospital, stating that Ellie-May was at risk of serious/life-threatening asthma, she should have recorded that prominently on Ellie-May’s clinical record. If she had done that, then that would have been obvious to her when the clinical records were opened.”

Clark said her daughter had been wheezy when she collected her from Malpas Court primary school at 3pm on 25 January.

She carried her crying daughter to her mother’s house and phoned the doctor’s surgery. A receptionist phoned back at 4.35pm and booked Ellie-May for an emergency appointment at 5pm – with Clark immediately warning that she might be late.

Clark said she arrived at the surgery at 5.05pm and waited to speak to the receptionist, Ann Jones, who phoned Rowe but was told that Ellie-May had to return for an appointment in the morning, as she was late.

Asked about the 10 minute rule, Rowe said: “If you have 25 patients to see in a morning or afternoon and a lot of people are 15 minutes late or 20 minutes late, you are never going to be able to manage your work.”

Recording a narrative conclusion, the Gwent coroner, Wendy James, said: “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.

“Ellie-May Clark died of natural causes where the opportunity to provide potentially life-saving treatment was missed.”

The coroner added: “Ellie’s care was disjointed. There was no one doctor or clinician allocated to oversee Ellie’s long-term management or care even though she suffered with a life-threatening condition. She was dealt with by three doctors in the surgery in five days. Had she been seen by one doctor, things maybe been different for Ellie.

“It is unacceptable that patients should be refused to be seen at an emergency appointment without any clinical assessment of their condition or any advice given. Especially when that patient is a five-year old child with a history of severe acute asthma.”