Five-year-old Ellie-May Clark, who had life-threatening asthma, was wheezing, unable to walk and crying when her mother collected her from school on January 25.
She was booked in for an emergency appointment at the Newport surgery but was refused the appointment by Dr Joanne Rowe who had a policy for not seeing patients more than ten minutes late.
Her mother took her home, rebooking another appointment the following morning, but Ellie-May Clark died that night.
Shanice Clark said her daughter, who was diagnosed with asthma in November 2011, had been off school for four days prior the incident due to her wheezing.
The GP was aware of her condition after a consultant wrote to stating that the child “previously had severe exacerbations of asthma requiring admission to the high dependency unit”.
“This places her at risk of having another episode of severe/life threatening asthma,” it said.
Miss Clark said that she had phoned the doctor’s surgery at 3.30pm to request a home visit.
A receptionist phoned back at 4.35pm and booked Ellie-May for an emergency appointment at 5pm – with Miss Clark immediately warning that she might be late.
Miss Clark, who had an eight-week-old baby at the time, said she arrived at the surgery at 5.05pm and waited in line to speak to the receptionist.
She said she reached the front of the queue between 5.10 and 5.18pm but Dr Rowe refused to see Ellie-May because the “ten minute deadline” had passed.
Receptionist Ann Jones phoned Dr Rowe but was told that Ellie-May had to return for an appointment in the morning, as she was late.
“We got outside and because I was angry, I got upset,” Miss Clark said. “When Ellie-May saw me upset she started getting upset. She said ‘why won’t the doctor see me?’.”
Miss Clark returned home with her daughter, who she checked on every 10-15 minutes, giving her an inhaler every 30 minutes or so.
She heard Ellie-May coughing at 10.30pm and went into her bedroom to give her an inhaler.
“She fell off her bed onto the floor,” Miss Clark said. “I turned her light on and I saw her hands and her face were blue. I rang 999 straight away.”
The little girl died shortly after arriving at the Royal Gwent Hospital.
Ellie-May’s inquest in Newport heard Dr 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”.
But Dr Rowe did not ask the reason behind Ellie-May’s emergency appointment, or look into her medical notes before refusing to see her.
Rob Sowersby, representing Ellie-May’s family, told the inquest Ellie-May’s mother was “sure” that the usual treatment provided to the girl when she attended the surgery – steroids – would have helped as they had in the past.
“There is no reason to suggest they wouldn’t have worked this time,” Mr Sowersby said.
The inquest heard receptionist Mrs Jones did not ask why Ellie-May was late for the appointment, nor about her condition, and did not give any advice on what to do if her condition worsened.
Mrs Jones told the inquest that Dr Rowe adhered to the “10 minute rule” more than other doctors at the surgery and had turned another patient away earlier that day.
Dr Rowe had no appointments between 4.50 and 5.20pm but did not check Ellie-May’s notes and was seeing another patient when Mrs Jones phoned to say that she had arrived.
The inquest heard Dr Rowe could have asked another doctor to see Ellie-May, could have seen her after her patient had left and could have spoken to the doctor who arranged the emergency appointment for her.
When asked why she had not, Dr Rowe replied: “I don’t know. I was busy seeing to the other patient that I had with me.”
She confirmed she would have acted differently if she had seen Ellie-May’s notes or the reason for the appointment.
A post-mortem examination by Dr 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.