A Welsh coroner has ruled it was unacceptable that a five-year-old girl died after she was turned away by doctor Joanne Rowe for being minutes late to her appointment, back in 2015.
Ellie-May Clark was scheduled for an emergency appointment because of breathing difficulties related to her asthma. Mother Shanice Clark had phoned the clinic at 3:30 pm to say that her daughter was wheezing and unable to walk. The clinic did not phone back until an hour later, offering her an appointment at 5:00 pm. Shanice warned that she might be late, as she had an 8-month-old baby and did not have a car.
According to Shanice, the two arrived five minutes late to the appointment but had to wait for the receptionist to finish taking her phone call and talk to a patient in front of them in line. By the time the call was done, the two were officially more than ten minutes late to their appointment, and Dr. Joanne Rowe refused to see them. Allegedly, Dr. Rowe said “she wouldn’t see Ellie as she was late and she would need to come back the following day,” without asking why she was late, opening her file, or asking the reason for the emergency visit. Shanice also said that, on leaving the clinic, Ellie-May asked, “Why won’t the doctor see me?”
After being sent home, Shanice put her daughter to bed at 8:00, and checked on her every 10-15 minutes. At 10:30, she found that her daughter’s face and hands had gone blue. “She fell off her bed onto the floor,” she said, during the recent inquest. “I turned her light on and I saw her hands and her face were blue. I rang 999 straight away.” Ellie-May died less than an hour later, at the Royal Gwent Hospital. The postmortem, performed by Dr. Andrew Bamber, revealed that she had died from bronchial asthma and may have suffered a seizure related to oxygen depletion before her death.
According to receptionist Ann Jones, Dr. Rowe (above) was a stickler for the clinic’s 10-minute rule and had turned away another patient earlier in the day. During the inquest, Dr. Rowe defended the necessity of the rule, saying, “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.”
Dr. Rowe had previously received a letter from a consultant stating that Ellie-May had severe asthma, but did not check her patient notes before the appointment. She had no appointments between 4:50 and 5:20. When asked if she would have acted differently if she’d known about Ellie-May’s condition, Dr. Rowe said that she would have. “Dr. Rowe made a clinical decision without any clinical information whatsoever,” lawyer Rob Sowersby told the inquest. “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.”
Coroner Wendy James said it was “not acceptable” that Ellie-May had been sent away without giving her mother any advice on what to do if her condition got worse. In her verdict, she said, “From the evidence before me, 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.” The family was “disappointed” that the coroner did not deliver a verdict of neglect, and that Dr. Rowe is still practicing medicine.
Dr. Rowe’s insurance company has offered Shanice £15,000 in compensation, but Shanice says that the offer feels like “an insult.” “There’s a large part of me that just doesn’t want it,” Shanice (above) told The Mirror. “How do you put a price on the life of a beautiful little girl? I would feel it was an insult to Ellie-May’s memory whatever they offered me.”
But she hopes that her tragedy will inspire others: “All I want is for this to never happen again. A parent somewhere in the country will be turned away at a surgery and think of my little girl and they will make a fuss, they will refuse to leave, and their child will be seen and be saved. That’s all I want.”
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