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A 5-year-old girl in Wales died of an asthma attack only hours after she was turned away from an emergency appointment with a doctor, because she was more than 10 minutes late.

According to the BBC, the girl and her mother showed up late because when they called for help, they were given only 25 minutes to arrive, and the mother had to arrange child care and catch a bus.

Evidence at an inquest for the death of Ellie-May Clark indicated that she and her mother were at Grange Clinic in Newport, Wales, in the United Kingdom  after the 5 p.m. appointment time, but she was not seen because of a “10-minute rule.”

A coroner described it as a missed chance to “provide potentially life-saving treatment.”

Ellie-May’s mother, Shanice Clark, BBC reported, said she requested a home visit when her daughter was breathing hard and unable to walk home from school. Instead she was told to bring in the child within 25 minutes.

After the childcare arrangements and bus ride, she said she arrived five minutes late, although the woman who was the receptionist at the time testified she was 18 minutes late.

“The child’s mother was then told by GP Dr. Joanne Rowe, a partner in the surgery and its lead for child safeguarding, that she would have to return in the morning,” BBC said.

The report explains Rowe did not ask the reason for the appointment or look at the girl’s medical notes.

Clark, according to testimony, checked on her daughter every few minutes during the evening and noticed at 10:30 she was coughing. Clark said she then fell off the bed and turned blue.

She was taken to Royal Gwent Hospital by ambulance but died.

The family issued a statement saying it was “disappointed that a finding of neglect was not reached.”

The report said the coroner will be in communication with the clinic over “the lack of an effective and robust care plan” for the girl.

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