A five-year-old girl died of a severe asthma attack in 2015 in the United Kingdom after a doctor refused to see her because she was late to an appointment, a coroner’s inquest found Monday.
Ellie-May Clark’s 2015 death at a hospital in Newport, Wales, prompted the inquest by the U.K. coroner.
The report found that the little girl was denied “potentially life-saving treatment” for her severe asthma because she had been late to her appointment because the doctor had a strict “10-minute rule,” the local media reported.
“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,” coroner Wendy Jame said.
“Especially when that patient is a five-year-old child with a history of severe acute asthma.”
Ellie-May’s mother Shanice Clark told the inquest that she first requested a home visit from the Grange Clinic when the attack first started, but was given an emergency appointment at 5 p.m., only 25 minutes later, the BBC reported.
WATCH: Health Matters: Feb. 26, 2018
Clark said she told the receptionist she might be late because she needed to find childcare for her eight-week-old baby and would be taking the bus.
When she and Ellie-May got to the clinic, Clark said she spoke to the receptionist by 5:10 p.m. But Ann Jones, the former receptionist, told the inquiry Clark and her daughter arrived 18 minutes past the appointed time, the BBC said.
That’s when Dr. Joanne Rowe told the pair they were too late, and because of the strict rules, they would have to come back in the morning.
But after Ellie-May went to bed, around 10:30 p.m., Clark heard her coughing. She was rushed to the hospital by ambulance; her hands and face were blue.
“She fell off her bed onto the floor,” Clark said, according to the Telegraph. “I turned her light on and I saw her hands and her face were blue. I rang 999 straight away.”
Rowe told the inquest that she hadn’t checked Ellie-May’s records, which contained a letter about the severity of her asthma, before sending the Clarks away.
Rowe said if she had seen the notes, or known the reason for Ellie-May’s appointment, she would have acted differently.
For Ellie-May’s family, the results of the inquest fell short.
“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,” the family said outside the court in Newport, the Guardian reported.
The coroner, James, said there was no way to know “with certainty” if earlier treatment would have saved Ellie-May’s life, but that there were missed opportunities.
“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,” James said.
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