A 5-year-old asthmatic girl died after a British clinic refused to treat her when she arrived just minutes late to her emergency appointment, according to a coroner.

Ellie-May Clark was wheezing and struggling to walk when she and her mother, Shanice Clark, arrived at The Grange Clinic in Newport, South Wales, on January 25, 2015, her mother told Wales Online

Clark, who was also caring for her 8-week-old child and did not have a car, had only 25 minutes to get her family to the clinic for a 5 p.m. appointment with Doctor Joanne Rowe. Prompt arrival was critical: Rowe had a policy of refusing patients who arrived 10 or more minutes late. But by the time Clark made it to the clinic and then the front of the line, she had just missed that deadline, according to the coroner.

Sticking to her "10-minute rule" Rowe refused service to Ellie-May, despite her difficulty breathing and inability to walk. The surgeon told Clark to come back the next day, but at 10:30 p.m. that night, a coughing fit seized Ellie-May and she began to turn blue. Ellie-May was rushed to a local hospital but she could not be saved. 

An autopsy revealed that she died from bronchial asthma and may also have suffered a seizure some time before her death. 

Rowe was aware of Ellie-May’s “serious/life-threatening asthma” but did not note the condition prominently on her medical record. The doctor did not consult that record before turning the girl away, an investigation into the incident found.

Coroner Wendy James said it was "not acceptable" that Rowe refused Ellie-May service without any medical evaluation or offering advice on what to do if her conditioned worsened. James did not, however, find neglect in the case, as Ellie-May's family had asked for, according to the Independent.

"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 [general practitioner] that day and she was let down by the failures in the system," James said. "Ellie-May Clark died of natural causes where the opportunity to provide potentially life-saving treatment was missed."