Girl, five, died of an asthma attack after her GP refused to treat her because she was FOUR MINUTES late to an emergency appointment... even though the doctor knew the youngster's life was at risk

• .Ellie-May Clark died of an asthma attack after Dr Joanne Rowe refused to see her
• .Her distraught mother, Shanice, said they were 4 minutes late for appointment
• .Dr Rowe was warned the girl was at risk of suffering a life-threatening seizure
• .Ellie stopped breathing an hour after she was put to bed, and died minutes later

By Tom Bedford and Michael Powell and Stephen Adams for The Mail on Sunday

A critically ill little girl died hours after a GP refused to see her because she turned up a few minutes late for an emergency appointment.

Astonishingly, the doctor is still practising after escaping with a ‘slap on the wrist’ at a secret disciplinary hearing.

Ellie-May Clark, five, died of an asthma attack after Dr Joanne Rowe refused to see her – despite having previously been warned the girl was at risk of suffering a life-threatening seizure.

The child’s distraught mother, Shanice, last night said they were just four minutes late for the appointment.

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Ellie-May Clark, five, died of an asthma attack after Dr Joanne Rowe refused to see her - because she was four minutes late

An official report, uncovered by The Mail on Sunday, stated they were eight minutes late, but Shanice insisted that was incorrect as she checked the time on her mobile phone when she arrived. 

They were sent home and told to return in the morning, but Shanice discovered her ‘bright and happy’ daughter having an asthma attack and not breathing an hour after she put her to bed that night. She died minutes later.

Details of the appalling blunder would have remained secret, because the doctors’ watchdog, the General Medical Council, held her disciplinary hearing behind closed doors. 

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Dr Rowe was suspended for six months on full pay after Ellie-May’s death in January 2015

But the full facts can now be revealed following a Mail on Sunday investigation, which discovered a ‘confidential’ NHS report which damned Dr Rowe’s handling of the incident.

It concluded that:

• The ‘root cause’ of the girl’s death was Dr Rowe’s refusal to see her;

• The GP turned Ellie-May away without asking a single question about the girl’s condition;

• Months earlier, a paediatrician had written to Dr Rowe warning that Ellie-May was ‘at risk of another life-threatening asthma attack’;

• Staff were ‘fearful’ of questioning Dr Rowe because of her ‘repeated angry outbursts’ and ‘volatile’ nature;

• Minutes after the Clarks went home, another GP questioned why Dr Rowe had turned them away.

• Dr Rowe claimed to have been ‘in the middle’ of seeing a patient when Ellie-May arrived, but the surgery’s computer system showed that was not the case.

Dr Rowe, 53, was suspended for six months on full pay after Ellie-May’s death in Newport, South Wales in January 2015. The case was heard behind closed doors because the GMC allows GPs to avoid public ‘fitness to practise’ hearings if they accept a proposed sanction – a process designed to help doctors avoid the ‘stress’ of public scrutiny.

Dr Rowe agreed to accept a written warning not do it again.

But last night campaigners said the current system puts patients at risk. Sir Donald Irvine, a former president of the GMC, warned the watchdog needed ‘urgent reform’. He said: ‘The GMC is there to protect the public, not for the convenience of doctors.’

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A report from the local health board, which oversees GPs’ surgeries, told how Ellie-May's mother Shanice rang The Grange Clinic for an emergency appointment

While the GMC’s closed inquiry was ongoing, Dr Rowe secured a job in another surgery in nearby Cardiff, where she works today. The Mail on Sunday understands none of Dr Rowe’s patients, past or present, has been informed of her fatal mistake.

Welsh Tory MP, Dr James Davies, a qualified GP, said he would urgently raise the matter with the GMC ‘in the interests of transparency’.

Last night Ellie-May’s grandmother, Brandi, said: ‘We’ve never even had an apology from Dr Rowe, who got away with just a slap on the wrist after her clock-watching attitude killed our beautiful girl.

‘She has been allowed to get on with her life, get another job and forget about it. But we have been left with nothing but pain. Ellie-May has been denied the life she should have had.’

A report from the local health board, which oversees GPs’ surgeries, told how Shanice rang The Grange Clinic for an emergency appointment at 3.20pm on January 26, 2015, as Ellie-May had suffered an asthma attack at school. Surgery staff knew the girl, and had helped her cope with five asthma ‘exacerbations’ in the previous six months. She had also ended up in a high dependency unit five times before that.

A GP called Shanice back at 4.32pm, agreed Ellie-May needed a face-to-face consultation, and offered a 5pm emergency slot with Dr Rowe.

Shanice arrived at the surgery with Ellie-May just after 5pm. According to the NHS report, Shanice said she arrived at ‘about 5.08pm’.

However, she insisted to this paper it was 5.04pm. Mother and daughter then waited several minutes while the receptionist dealt with a phone call and another patient.

The receptionist finally addressed Shanice at 5.18pm, the report notes, calling through to Dr Rowe to ask if she would see them. According to the receptionist’s account, the GP then ‘shouted something like “No I’m not seeing her, she’s late”.’ 

The receptionist replied: ‘She’ll have to come back in the morning, won’t she?’ The report says that Dr Rowe pointed out to the receptionist that the patient was more than ten minutes behind schedule so too late to be seen, and agreed Ellie-May should come back in the morning.

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From the NHS ‘Serious Concern’ report...computer records showed Dr Rowe had no other patient in her office

After the Clarks went home another surgery doctor questioned Dr Rowe’s decision, telling a receptionist ‘that they could not turn emergency appointments away’. 

At 10.35pm Shanice discovered Ellie-May was having an asthma attack and had stopped breathing. She rang 999 but despite attempts by family, ambulance paramedics and doctors at Royal Gwent Hospital, Ellie-May could not be saved.

When the health board investigated, it found Dr Rowe gave incorrect information, including her claim to be with another patient at the time. They also found that staff were ‘fearful of questioning’ Dr Rowe due her ‘angry outbursts’.

It concluded the ‘root cause’ of the child’s death was that Dr Rowe ‘refused to see EM [Ellie-May] because she was brought in late’. It also noted that months earlier a hospital paediatrician had written to Dr Rowe warning that Ellie-May was ‘at risk of another episode of severe / life-threatening asthma’.

Despite this, the report said, Dr Rowe ‘did not make any clinical assessment of EM before refusing to see her’ and failed to give her mother any ‘safety netting advice’.

The ‘serious concern’ was passed to the GMC but Dr Rowe was allowed to continue practising with only minor restrictions.

Last May she attended a closed-doors meeting where she agreed to a written warning, which will be wiped from her record after five years. The perfunctory 294-word warning, buried on the GMC’s website, says Dr Rowe ‘declined to see a child patient’ who was late and ‘did not consider’ that the child ‘had a history of severe asthma’. ‘The child died later that evening of asthma,’ it states. ‘Your failure to see and assess this child does not meet with the standards required.’

But it concludes the failing was ‘not so serious’ as to warrant suspension or a ban.

Dr Rowe declined to respond to the health board’s report.

The Grange Clinic referred The Mail on Sunday’s detailed questions to Aneurin Bevan University Health Board, which refused to answer, insisting we lodge a Freedom of Information request instead.

A spokeswoman said: ‘Our thoughts remain with the family and friends of Ellie-May. We can confirm that Dr Rowe no longer works within the health board area, and also that we referred the doctor to the GMC who investigated in accordance with their procedures.’

Charlie Massey, chief executive of the GMC, said: ‘We extend our deepest sympathy to the family for their loss. This doctor has a clear warning against her medical register entry, detailing the shortcomings in the care she provided.

‘It’s clear that in this case the family was not given all of the information necessary to understand why we took the action that we did. We will review our arrangements to make sure those processes work in the best interests of families.’