LESSONS must be learned says a coroner, from the “tragic” death of a five-year-old girl with severe asthma who died hours after being turned away by a GP when her mum was late getting her to an emergency appointment.

Despite her tender years little Ellie-May Clark, of Malpas, Newport, recognised her symptoms were worsening on Monday January 26 2015.

After school she told mum Shanice Clark she wanted to go to the doctor’s to get her “pink medicine”.

Refused a home visit, Ms Clark was then given just 25 minutes to get Ellie-May to the Grange Surgery in Malpas for an emergency appointment.

With no transport of her own and having to arrange a lift, Ms Clark warned the surgery she may be late and she was - late enough for GP Dr Joanne Rowe to refuse to see Ellie-May.

A ‘10-minute rule’ applied - if a patient was later than that for an appointment, they would be told to come back for the next morning’s open surgery.

But there was to be no next morning for Ellie-May. She died that evening, having suffered a seizure as her condition worsened.

At the inquest, it was revealed that Dr Rowe had not seen the triage note from Ms Clark’s call, and had not looked at Ellie-May’s records.  Rob Sowersby, counsel for Ellie-May’s family, asked Dr Rowe: “Do you think it is acceptable that you turned Ellie-May away without seeing her?”

Dr Rowe replied: “No. I don’t. I should have seen her or got the duty doctor to see her.”

The inquest was told that a consultant’s letter was sent to the surgery in May 2014, after Ellie-May was hospitalised with breathing problems.

It stated that Ellie-May had suffered “severe exacerbation of asthma”, and was “at risk of having another episode of severe/life threatening asthma.”

Dr Rowe admitted that though she had initialled it, she had not placed it prominently on Ellie-May’s record, where it would be one of the first things a doctor would see.

“Is it even more important to do that with a child patient?” asked Mr Sowersby.

Dr Rowe replied: “Yes.”

She said that when the receptionist told her Ellie-May and her mum had arrived, she was with another patient, so could not have looked at her record.

She said the decision not to see her was not made on the basis of clinical information. She had been “in the middle of seeing another patient” when called, and would only have seen the asthma warning had she opened the notes.

Ann Jones, a former receptionist at the surgery, said she asked Dr Rowe if Ellie-May would have to be brought back the next morning.

“Dr Rowe said she was not seeing her as it was too late,” said Mrs Jones.

She added that Dr Rowe did not ask why Ellie-May had an appointment, and Ms Clark was “very sad” when told she would not be seen that day.

A post mortem examination revealed Ellie-May died of bronchial asthma. There was evidence of severe acute asthma and chronic inflammation, likely due to a viral infection that may have caused her worsening condition.

Senior coroner for Gwent Wendy James concluded the five-year-old died of natural causes, where the opportunity to provide lifesaving treatment was missed.

She concluded that neglect had not played a part in Ellie-May’s death, a link not having been established between her death and the doctor failing to see her.

But Ms James said Ellie-May was failed by the system, and is preparing a Regulation 28 letter, which highlights concerns and is intended to help prevent future deaths.

It will be sent to partners at Grange Surgery and to Aneurin Bevan University Health Board, and will raise concerns over: l The lack of an effective and robust care plan for Ellie-May; l The turning away of patients with emergency appointments if they arrive late, without looking at records or giving advice; l Support staff feeling they do not have sufficient support to challenge GPs’ decisions or seek a second opinion; l Insufficient time for patients to attend emergency appointments; l Triage notes not being made available to GPs who are seeing patients; l The warning letter not being displayed prominently in Ellie-May's notes.

At the close of the hearing, Dr Rowe, through her counsel, said she was “sincerely sorry”.

In a statement, Ellie-May’s family remembered a “happy” girl and, while acknowledging Dr Rowe’s apology, expressed their disappointment that a finding of neglect was not reached.