Ellie-May Clark was having a severe asthma attack when she arrived 10 minutes late with her mother Shanice at The Grange Clinic, in Newport, Wales

Ellie-May Clark was a bubbly girl, with a mass of wavy brown hair and a mischievous smile. She loved her sequinned party dress and playing on her trampoline, and was described by her proud family as ‘a little princess.’

The fact she had suffered from severe asthma since the age of two didn’t seem to dent her enjoyment of life. She took her ‘pink medicine’ — the steroids that helped her to breathe more easily — with good grace and was thriving in her first year of school.

But what this bright, ambitious girl — labelled an ‘absolute joy’ by her teacher — could grow up to achieve will never be known, because Ellie-May died of a seizure on the evening of January 26, 2015, aged just five.

Her asthma symptoms had progressively worsened on the day of her death. In the morning, her teachers noticed her rasping cough. Then there was the fact she couldn’t finish her lunch. Eventually her breathing became laboured to the point where she struggled to walk.

After receiving a call from the school to say she had required her inhaler, Ellie-May’s concerned mother, Shanice, collected her daughter early and rang Grange Clinic, the family’s GP surgery in Newport, South Wales.

Shanice called the practice at 3.30pm, reporting that Ellie-May was wheezing and could not walk, but Shanice was not phoned back for an hour, when she was offered the 5pm appointment.

With a child who was struggling to breathe, walking to the surgery wasn’t an option, and Shanice told the receptionist she was doubtful she’d be able to get from her home on time.

But, all too aware how important this appointment was, she tried her best, arranging a lift with a friend — Shanice didn’t have a car and it was quicker than her other option of travelling by bus — before dropping her baby at her mother’s house, 1.5 miles from the surgery, and driving in.

She says she was just five minutes late. There was, however, a queue at the surgery and by the time she’d reached the front of that queue and spoken to the receptionist it was between 5.10pm and 5.18pm.

That, according to her GP, Dr Joanne Rowe, was too late for her to be seen.

Had Dr Rowe consulted Ellie-May’s medical records — which would have shown a paediatrician’s letter from the previous year she herself had signed to acknowledge, warning that Ellie-May was at risk of a ‘life-threatening’ asthma attack — she might have reconsidered.

Ellie-May's mother Shanice Clark (left) and GP Dr Joanne Rowe (right) are pictured arriving at the inquest hearing. Dr Rowe has been given a warning at a private hearing

As it was, the GP — a stickler for time-keeping who was also the surgery’s lead doctor for child welfare — could not be persuaded.

Rather than report why she had turned Ellie-May away, Dr Rowe logged ‘did not attend — no reason’ into the girl’s records, leaving a distraught Shanice to return to the surgery in the morning and prompting her poorly little daughter to ask: ‘Why won’t the doctor see me, Mummy?

Around two hours after putting Ellie-May to bed that evening, Shanice discovered that Ellie-May was having an asthma attack and had stopped breathing. An ambulance was called and she was rushed to Royal Gwent Hospital, but attempts to resuscitate her failed. Some six hours after visiting the Grange Clinic, she was dead.

A post-mortem examination by Andrew Bamber found that Ellie-May had died from bronchial asthma and may have suffered a seizure before her death because of a lack of oxygen.

Unsurprisingly, the inquest into Ellie-May’s death this week at Newport Coroner’s Court — at which Dr Rowe admitted that it had not been ‘acceptable’ to turn the girl away — issued a dire indictment of Ellie-May’s care.

On delivering a conclusion, Gwent coroner Wendy James said ‘the opportunity to provide potential life saving treatment was missed’ and that ‘Ellie-May was let down by the system.’

A tearful Shanice, 26 and a single mother, afterwards said she was ‘disappointed’ that the coroner ruled out neglect.

‘I will have to live with the fact that my little girl was sent home to die by a doctor who refused to see her because we were a few minutes late,’ she said.

Dr Joanne Rowe (left, arriving at the Newport inquest), 54, refused to see Ellie-May Clark (right), sending her home without even looking at her medical records

‘I want justice for Ellie-May and I want to make sure this doesn’t happen to another child.’

Aside from the tragedy of a young life lost, and a family left to flounder amid unimaginable grief, Ellie-May’s death raises grave concerns over the manner in which the General Medical Council — the public body responsible for maintaining the medical register and protecting patients — has handled the case.

Rather than referring Dr Rowe to a tribunal to ascertain whether she should be censured, it held a ‘fitness to practice’ hearing in private before issuing the GP with a warning.

As a result, Dr Rowe — who’d been suspended on full pay for six months as her conduct was investigated — was free to continue her career, and is currently working for another GP surgery in nearby Cardiff.

‘We wanted her struck off, but she was allowed to return to work as if nothing happened,’ Ellie-May’s grandmother, Brandi, said. The GMC’s actions seem open to question given the contents of the confidential report into Ellie-May’s death — a report seen by the Mail this week.

This internal investigation, compiled by Aneurin Bevan University Health Board, which is responsible for the Grange Clinic, paints a portrait of Dr Rowe as an aloof and unapproachable GP capable of treating patients and colleagues alike with disdain.

It states clearly that ‘Dr D [as Dr Rowe is referred to in the paperwork] refused to see EM [Ellie-May], knowing that she was a child, because she was brought in late for an emergency appointment and she did not make any clinical assessment of EM either directly or indirectly before refusing to see her.’

Around two hours after putting Ellie-May to bed that evening, Shanice discovered that Ellie-May (pictured) was having an asthma attack and had stopped breathing

The way in which Dr Rowe reportedly turned Ellie-May away — according to receptionist Ann Jones with a brusque, ‘No, I’m not seeing her. She’s late’ — seems even more questionable given Dr Rowe’s schedule that day.

Although her afternoon surgery started at 3pm, she didn’t call in her first patient until 3.15pm and out of the 15 available slots she had that afternoon she only saw 11 patients, and spent an average consulting time of 7.5 minutes, out of the allotted 10 minutes, per patient.

One would have thought she might have been able to squeeze Ellie-May — who had been hospitalised five times for her asthma between February 2013 and March 2014 — in somewhere.

The report also reveals this wasn’t the first time Dr Rowe had sent away patients, as the GP ‘has indicated it is her usual practice to act in this way when patients attend late for either routine or emergency appointments.’

More worrying still, it exposes a ‘negative culture’ at the surgery and ‘a consensus among the reception staff that Dr D is unapproachable and volatile, even more so on the days she is on call.’

There had, it was recorded, been complaints from her colleagues who reported ‘being afraid to challenge her decisions or seek a second opinion from one of the other doctors.’ All of which begs the questions: why, after reading this, did the GMC not view Dr Rowe’s professional conduct as deserving further sanction?

Didn’t her patients — many of whom had no idea why she’d left the practice until they read about the case in the paper — deserve to know the truth?

And, given her treatment of Ellie-May, and the family’s concerns, should Dr Rowe still be working for the NHS at all?

An imposing woman, Dr Rowe, 54, a married mother-of-two from Cardiff, studied medicine at the University of Bristol before joining the Grange Clinic 22 years ago.

‘I immediately felt rushed as soon as I knocked on her door,’ one ex-patient told the Mail. ‘Dr Rowe barely seemed to look away from her computer screen — it was impossible to make eye contact with her. The appointments never seemed to last longer than five minutes.’

What made Dr Rowe’s demeanour worse, says the married mother-of-two, whose identity the Mail has agreed to withhold, was she had visited the practice for a private gynaecological condition.

Ellie-May’s concerned mother, Shanice, collected her daughter early and rang Grange Clinic, but Shanice was not phoned back for an hour, when she was offered the 5pm appointment

Despite Dr Rowe stating that her ‘special interests’ include family planning procedures, the former patient says the GP appeared entirely disinterested in the persistent pelvic pain that she was suffering from.

‘There was always a sense I was wasting her time. She made me feel too intimidated to ask questions.’

She says it had often taken her up to three weeks to get an appointment at the Grange Clinic in the first place.

Also, there could be a queue of people snaking into the surgery car park waiting for ‘on the day’ appointments as early as 7.30am, and even after she’d been booked in the ex-patient often had to wait for ‘over an hour’ to see a GP.

‘There wasn’t always a seat for everyone,’ she says. ‘Children sat on parents’ knees and people stood waiting in the corridors. The windows were barred up, there was no ventilation and we’d all be coughing and spitting on top of each other.’

Of course, every GP, rightly or wrongly, will rub some patients up the wrong way, but the fact that so many patients at Grange Clinic seem to have been forced to wait endlessly for delayed appointments only makes Dr Rowe’s decision not to see a delayed child all the more difficult to understand.

‘I remember being kept waiting to see this very doctor because she was late back to the surgery,’ writes one patient on petition website change.org.

‘It appears that it’s OK for a doctor to keep patients waiting, but not for patients to be a few minutes late.’

The Health Board’s report acknowledges that it wasn’t just Dr Rowe’s decision that let Ellie-May down but wider communication problems at the Grange Clinic.

It found that the receptionist who took Shanice’s call was not the same receptionist that Shanice met when she arrived, and the doctor who was consulted regarding the emergency appointment before Shanice and Ellie-May’s arrival was not Dr Rowe.

It recommended that the ‘practice must review the system for supporting patients, particularly for prioritising urgent requests, and ensure that a safe, consistent and effective system is in place.’

A spokesman for Aneurin Bevan University Health Board said: ‘We fully investigated this matter and subsequently made a referral to the General Medical Council (GMC) which investigated in accordance with their procedures.’

A spokesperson for Dr Rowe, meanwhile, repeated the statement that was read by the inquest counsel:

‘Dr Rowe knows nothing could be said to Ellie-May’s family to make a difference but she would like to say how sincerely sorry she is for the tragic events in January 2015.’

Ellie May's computer records at The Grange Surgery (pictured) stated she was in danger of having a life-threatening asthma attack and had been previously admitted to intensive care

Charlie Massey, the chief executive of the GMC, told the Mail: ‘This was a tragic case and we would like to extend our sincere condolences to Ellie-May’s family.

‘Patient safety is at the heart of everything the GMC does and we do not hesitate to take action where we judge that doctors who have made mistakes continue to pose a threat to patient safety.

‘Any doctor who receives a warning, which can be seen by any patient and employer, has had to account for their actions and prove they have taken the steps necessary to remedy them.

‘They are also subject to regular checks which require them to reflect on serious issues or complaints through mandatory annual appraisal.’

‘Since this case we have taken steps to make information about recent decisions more accessible to the public.

‘We have created a new page on our website listing recent decisions which includes warnings.’

Dr Rowe’s warning will be publicly available on the medical register until 2021. Which is all very well, but how many patients would think to look on the GMC website, let alone the medical register, when considering a prospective GP?

Not the former Grange Clinic patient that the Mail spoke to, who learned that Dr Rowe had left the practice only after reading about Ellie-May’s death in her local newspaper last year.

‘I was shocked, then annoyed that we weren’t informed,’ said the ex-patient. ‘I think the surgery should have explained what happened.

‘Given the clear concerns about how Dr Rowe dealt with the situation, I can’t believe she’s been allowed to continue practising.’

It is a sentiment that a number of patients might agree with.