A 5-year-old girl with a history of asthma died mere hours after a doctor turned her away for being minutes late to an appointment, according to officials.

An inquest determined that Ellie-May Clark was not seen at Grange Clinic in Newport, Wales, for an emergency appointment because they enacted a “10-minute rule.” As a result, a coroner testified that an opportunity to “provide [a] potentially life-saving treatment was missed,” the BBC reported.

According to Wales Online, Shanice Clark, who had recently given birth to another child, requested a home visit in January 2015 but was given 25 minutes to get to the clinic. Sky News reported that Dr. Joanne Rowe allegedly turned Ellie-May away despite a consultant alerting them that the patient was at risk for a “severe/life-threatening” asthma episode.

The family reportedly arrived at 5:05 p.m. for a 5:00 appointment. However, the little girl and her mother had to wait for a receptionist to finish her phone call and wait for a patient before them. They talked to the receptionist between 5:10 and 5:18—with the coroner noting that Dr. Rowe nor the receptionist asked why Ellie-May was late for the appointment or the reason for the emergency appointment.

“She said ‘Why won’t the doctor see me?’” Shanice recalled her daughter asking.

Additionally, the coroner accused Dr. Rowe of never looking at Ellie-May’s medical file. Dr. Rowe claimed she told the mother to bring Ellie-May back tomorrow for an appointment, which she agreed.

Ellie-May went to bed at 8:00 p.m. that day, with her mother checking on her every 10-15 minutes and giving her an inhaler every 30 minutes. Shanice claimed she heard her daughter coughing at 10:30 and discovered that her face and hands were blue. The child was taken to the hospital, where she died a short time later.

Officials said the cause of the 5-year-old’s death was bronchial asthma.

“Dr. Rowe knows that nothing can be said to Ellie-May’s family to make a difference but she would like to say how truly sorry she is,” a statement read at the inquest said.

Despite this, the heartbroken mother said she was “disappointed” that the coroner ruled out neglect for her daughter’s death.

“We all felt there was enough evidence to show my little girl was neglected by the medical profession,” she said after the hearing.

“I will have to live with the fact that my little girl was sent home to die by a doctor who refused to see her because we were a few minutes late.”

[Featured Image: Ellie-May Clark/Handout]