Ellie-May Clark: GP who turned away five-year-old shortly before she died was let off with warning by GMC

The GP who turned five-year-old Ellie-May Clark away from an emergency appointment shortly before she died, only received a warning from regulators and was allowed to keep practising.

An inquest heard that Dr Joanne Rowe had not looked at severely-asthmatic Ellie-May’s medical records before deciding not see her because she was late.

The South Wales GP confirmed she would have acted differently had she done so.

However both the coroner and the medical regulator stopped short of saying these failings merited serious sanction.

In May 2016, the General Medical Council (GMC) ruled that these actions “did not meet with the standards required of a doctor”.

However, its investigators concluded that it did not warrant her being put forward for a medical tribunal, which could lead to her being suspended or struck off, nor did they call for “conditions” on her practise, such as additional training or supervision.

Instead she was given an official warning, given when there has been a “significant departure” from GMC guidance. This will stay on her record until 2021.

Dr Rowe, who led on child safeguarding at the Grange Clinic in Newport, South Wales where Ellie-May was a patient - was suspended while the investigation was ongoing but is now back at work as a GP. She is practising in Cardiff.

While this decision is recorded in the public register, it is only disclosed to employers on request and the case never went to a public tribunal, leading some experts to call for reforms to make the process public.

This is not the first time that the GMC’s decisions have made headlines.

In January it went to the High Court to overturn a decision by its own tribunal service and ensure that paediatrics trainee, Dr Hadiza Bawa-Garba, was struck off after being found guilty of manslaughter by gross negligence.

Dr Bawa-Garba’s mistakes led to the death of six-year-old Jack Adcock in 2011.

But her supporters say unprecedented pressures and a lack of senior doctors on the ward were contributing factors and these had been considered by the GMC tribunal but not in court.

In each case the GMC’s acted against doctors whose failings could cause the medical profession to be brought into disrepute.

However in Dr Rowe’s case there were no criminal proceedings for the GMC to consider in its verdict and, apparently, no ongoing risk to patients.

While Ellie-May’s family had been hoping for a verdict of neglect, at the tribunal earlier this week, Gwent Coroner Wendy James concluded that the opportunity to provide “potentially life-saving treatment” had been missed leading to her dying of natural causes.

“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,” she added.

The coroner criticised the unacceptable failings of Dr Rowe, and “disjointed care” at the practice.

The GMC would consider any court proceedings in its verdict and act where it believes there is a threat to patients in future.

The details of the warning put forward by two GMC investigators, one from a medical background and one lay person, are published on Dr Rowe’s medical record.

It reads that Dr Rowe “declined to see a child patient who attended after the time of their booked emergency appointment, advising that the child should come back the next day."

It adds: “You did not consider the medical history of the child, or provide advice on how the child’s parents could access alternative medical care. The child had a history of severe asthma, and had experienced breathing problems that day.

“The child died later that evening of asthma.”

Despite this, the investigators concluded: “This failing in itself is not so serious as to require any restriction on your registration, it is necessary in response to issue this formal warning”.

The case is only referred for further hearing if the investigators disagree, or if the doctor disputes the evidence.

In this case the GMC confirmed to The Independent that Dr Rowe would have put forward information setting out how she would change her practising habits to prevent a repeat, but did not dispute the warning.

The inquest heard Dr Rowe could have asked another doctor to see Ellie-May, could have seen her after her patient had left and could have spoken to the doctor who arranged the emergency appointment for her.

When asked why she had not, Dr Rowe replied: “I don’t know. I was busy seeing to the other patient that I had with me.”

She confirmed she would have acted differently if she had seen Ellie-May’s notes or the reason for the appointment.

When asked about the “10 minute rule”, Dr Rowe said: “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.”