“Why won’t the doctor see me?” asked five-year-old Ellie-May Clark, who turned to her mother in the crowded waiting room of a busy doctor’s surgery on January 26, 2015.
She and her mother Shanice Clark had arrived to the surgery in South Wales 10 minutes late for their appointment and were turned away by the doctor.
That night, Ellie-May was found in her bed at 10.30pm not breathing. She died of an asthma attack brought on by a viral infection.
Now, after an inquest into her death failed to find negligence on behalf of the practitioner, 26-year-old Shanice says she is “disappointed” with the ruling.
“We all felt there was enough evidence to show my little girl was neglected by the medical profession,” she told Daily Mail after today’s hearing.
“I will have to live with the fact my little girl was sent home to die by a doctor who refused to see her because we were a few minutes late.”
The matter is made more troubling by the fact Ellie-May had life-threatening acute asthma and the seriousness of her condition was written all over her medical file. Her family believes that if the doctor had simply clicked into the records before sending the five-year-old away, perhaps Ellie-May would still be here.
This is how the afternoon unfolded.
Late in the afternoon of that fateful day three years ago, Shanice called The Grange Clinic in Newport because Ellie-May had suffered a severe asthma attack at school.
Shanice was refused a home visit and was told to be at the surgery within 25 minutes - by 5pm - for an emergency appointment with Dr Joanne Rowe, 54.
But life doesn't work like that.
Shanice is a single mother who also had an eight-week old baby at the time. She had to find someone to look after the baby and, by the time she and Ellie-May reached the end of the reception line at the clinic, it was 10 minutes after 5pm.
"I told the receptionist I was going to be late, I had to get someone to look after my baby," Shanice told the inquest, Daily Mail reports.
"I was five minutes late - there was someone in front of me in the queue and the receptionist was on the phone.
"I said to the receptionist I could not have gotten there any earlier but when she rang through to the doctor I was told I'd have to bring Ellie-May back in the morning."
The receptionist at the time, Ann Jones, confirmed to the inquest Shanice and her little girl arrived soon after 5.10pm. She said she "rang through and Dr Rowe said she would not see her".
Jones said she "apologised profusely" to a very upset Shanice but did not challenge the decision. "I am a receptionist. They are the doctors. It's their call," she told the inquest.
BONUS: what the mother of a very sick child wants you to know. Post continues below.
Dr Rowe has been in practice for 22 years. She admitted to the inquiry it was "not acceptable" that she sent Ellie-May away, and said she would have acted differently if she had opened the file and seen the seriousness of the girl's condition.
"I didn't open the records, I don't know why," she told the inquest, adding she was with another patient by the time the receptionist called.
She said her decision not to see Ellie-May "wasn't based" on any clinical evidence.
Outside the courtroom, Shanice said she is thankful for Dr Rowe's apology but still believes the general practitioner should have been found negligent for her failure to open Ellie-May's record.
Dr Rowe was reprimanded by the General Medical Council, Daily Mail reports, and the inquest verdict, handed down by coroner Wendy James, found:
"Ellie-May Clark died from natural causes where the opportunity to provide potential life-saving treatment was missed."