An inquest has heard how a five-year-old girl from Newport died after she was turned away from her GP for being late.
Ellie-May Clark, who suffered with asthma and her mother were five minutes late for the emergency appointment on January 25 in 2015.
The coroner said Ellie-May died of "natural causes where the opportunity to provide potentially life-saving treatment was missed."
Ellie-May's mother Shanice Clark had called the clinic for an emergency appointment after Ellie-May had been unable to walk home and was wheezing.
But Shanice said she was five minutes late for Ellie-May's five o'clock appointment and then had to wait in line to speak to the receptionist.
The inquest heard she reached the reception desk of The Grange Clinic in Newport between 5.10pm and 5.18pm.
But because the surgery had a "10 minute rule" for lateness, GP Dr Joanne Rowe told Shanice and Ellie-May to return the next day.
Ellie-May's condition worsened that night and she turned blue before being taken to hospital by ambulance.
She died in hospital - and it has taken more than three years for an inquest to be held into her death.
Ellie-May's family blamed "obvious neglect" for her death.
Her gran, Brandi Clark, said, "Ellie-May was the perfect child. She was happy and loving."