A coroner's inquest into the 2015 death of a 5-year-old British girl found that the child died just hours after a doctor refused to see her for being a few minutes late to her appointment, according to the BBC.

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Shanice Clark has been searching for answers ever since her daughter, Ellie-May, died from bronchial asthma hours after arriving late to an appointment with Dr. Joanne Rowe and being turned away. On Monday, the coroner ruled that Grange Clinic in Newport, Wales "missed" the opportunity to "provide potentially live-saving treatment" to her child, the New York Post reported.

While the clinic has maintained that it operates under a strict "10-minute rule," Clark insists she and her daughter were only five minutes late after arranging childcare for her infant and catching a bus. However, she claims she had to wait for a receptionist to finish a phone call and for other patients to be checked in, causing her to miss the 10-minute mark, Sky News reported. A clinic worker later indicated that she was 18 minutes late — something Clark disputes.

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According to the coroner, the occasion was the first time the rule had been imposed in regard to an emergency appointment, and Clark was reportedly told to come back in the morning without the doctor even looking at her daughter's medical records.

"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 [doctor] that day, and she was let down by the failures in the system," the coroner wrote, according to ITV.

Grange Clinic released a statement in response, saying, "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."

The Clark family responded by acknowledging the apology and by expressing disappointment “that a finding of neglect was not reached,” saying in a statement via their lawyer, “The family acknowledge an apology from Dr. Rowe, especially as they have been waiting in excess of three years for an outcome and to receive answers to their questions.”

The coroner will now write a report to the clinic and local health board aimed at addressing the incident and preventing similar tragedies in the future. In the meantime, a spokesman for Aneurin Bevan University Health Board said it would be "inappropriate to comment whilst we await the coroner's report."