A five-year-old girl with life-threatening asthma died after being turned away from an emergency doctor's appointment because she was late, an inquest heard.
Ellie-May Clark arrived at The Grange Clinic in Newport, south Wales, five minutes after her emergency appointment at 5pm on January 25 in 2015, her mother said.
She was booked in to see Doctor Joanne Rowe, a partner in the surgery and its lead for child safeguarding, as she was wheezing and unable to walk.
Ellie-May and her mother, Shanice Clark, waited in line to see receptionist Ann Jones and reached the front of the queue between 5.10 and 5.18pm.
Dr Rowe had a "10-minute rule", where she would not see patients who arrived more than 10 minutes after their appointments, and refused to see Ellie-May as she was late, an inquest heard.
Ellie-May asked "why won't the doctor see me?" before returning to the family home in Malpas, Newport, where she went to bed at about 8pm.
Miss Clark heard her daughter coughing at 10.30pm and called an ambulance after finding her struggling to breathe, with her hands and face blue.
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".
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: "Dr Rowe made a clinical decision without any clinical information whatsoever.
"She sent away a five-year-old patient from an emergency appointment without even opening her records.
"Dr Rowe agreed that when she opened the letter from the hospital, stating that Ellie-May was at risk of serious/life threatening asthma, she should have recorded that prominently on Ellie-May's clinical record.
"If she had done that, then that would have been obvious to her when the clinical records were opened."
Mr Sowersby said 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.
Miss Clark told the inquest that Ellie-May began suffering with a wheezy chest and was first admitted to hospital in November 2011, two months before her second birthday.
She was prescribed inhalers but returned to hospital every three to four months, with the last admission before her death in March 2014.
In May, a consultant wrote to The Grange Clinic stating: "Ellie-May has 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."
Dr Rowe received the letter but did not prominently record that Ellie-May was at high-risk on her medical records.
Ellie-May was kept off school for four days and attended the surgery on January 22 due to wheezing.
Miss Clark said her daughter was wheezy when she collected her from Malpas Court Primary School at 3pm on January 25.
She carried her crying daughter to her mother's house and 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.
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?'."
The inquest heard 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.
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."
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.
She phoned Dr Rowe at 5.18pm and informed her that Ellie-May had arrived for her emergency appointment but was told she would not see her.
This was the first time she had turned away a patient from an emergency appointment for being late, Mrs Jones said.
"I was always taught that you should never turn away children and the elderly," Mrs Jones said.
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.
"She said that she had arrived and she said 'I'll tell her to come back tomorrow morning, shall I?' and I said 'yes'," Dr Rowe said.
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.
When asked about the "10 minute rule", Dr Rowe said: "If you have 25 patients to see in a morning or afternoon and a lot of people are 15 minutes late or 20 minutes late you are never going to be able to manage your work."
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.