Calls have been made for a disciplinary panel to publish its findings into a GP who turned away a young girl who later died of an asthma attack.
Ellie-May Clark, five, and her mother, from Newport, were told to return the next morning by Dr Joanne Rowe because they were late.
Dr Rowe was given a warning by the General Medical Council (GMC).
Sir Donald Irvine, former president of the GMC, called for greater "transparency" in the case.
The GMC has apologised to the girl's family, saying it strives "to keep patients and their families fully informed" about investigations but failed to do so in this instance, adding that it would re-examine the rules around such cases.
It said it published the warning "on the online register for all patients and employers to see".
Ellie-May's relatives have called for a criminal inquiry into the doctor's actions, saying she should be struck off the GP register.
'Very good reasons'
Dr Rowe, 53, who lives in Cardiff and has now moved to another practice, declined to comment when contacted by the BBC.
The warning she was issued by the GMC will stay on her record for five years.
The council said her conduct risked "bringing the profession into disrepute and it must not be repeated" but did not go into any further detail as to why it chose that sanction.
Sir Donald said a number of recent GMC disciplinary hearings had been heard in private with no clear explanation, in the same way.
"I do think, where hearings are in private, the council has to be extremely careful that it gives very good reasons and publishes good reasons as to whatever decision it comes to," he told BBC Radio Wales' Good Morning Wales programme.
When asked if he believed the details of the GMC investigation and "confidential" findings that led to the warning should have been made public, he said: "I do.
"I believe in transparency. This is a public record and I think that any relatives and any patients are entitled to have a very clear understanding of why the GMC reached the decisions it did.
"And where you have a situation where there's a reprimand, if it just appears out of the air, with no explanation as to why that is appropriate, that's very unsatisfactory."
Speaking at the weekend, Ellie-May's grandmother, Brandi Clark, 43, said of the GP visit: "They were a few minutes late and Shanice [Ellie-May's mother] even told the receptionist they wouldn't be there on time.
"But Dr Rowe sent them away. Her decision cost our gorgeous little girl her life."
As The Mail on Sunday reported, Dr Rowe's practice had been warned by a paediatrician that Ellie-May was at risk of a life-threatening asthma attack.
She was sent home from school early on 26 January 2015 because teachers were concerned her asthma was "deteriorating".
Her mother, 25-year-old Shanice Clark, made an emergency appointment at the Grange Clinic in Newport and was told to get there at 17:00.
This gave her 25 minutes to arrange childcare for her two-month-old baby and ask a friend to give her a lift to the surgery a mile away.
Ms Clark claims her mobile phone was showing 17:04 when she arrived, but that she then had to queue at the reception desk.
After being turned away, Ms Clark took her daughter home and dialled 999 at 22:35 when she suffered a seizure and stopped breathing.
She was taken to the Royal Gwent Hospital, in Newport, by ambulance but later died.
Dr Rowe was a senior partner at The Grange Clinic for 22 years where she was in charge of child safeguarding at the practice.
An inquiry by the Aneurin Bevan health board, which controls the surgery, also found Dr Rowe had "failed to make any clinical assessment".
After being suspended on full pay for six months, Dr Rowe has since joined the Cloughmore Surgery in Splott, Cardiff.
The health board said it had referred the matter to the GMC, which investigated it "in accordance with their procedures".
A GMC spokesman said that, if a case is raised by an NHS body, such as a health board or trust, it is currently only required to report back to that body.
'We'd like to apologise'
However, if an investigation is requested by a patient or a patient's family, the GMC reports back to those individuals or their representatives.
Charlie Massey, chief executive of the GMC, said: "We strive to keep patients and their families fully informed about the progress of our investigations.
"We accept that this didn't happen in this case and we would like to apologise to the family for not doing so. We will contact the Clark family to discuss this further."
Mr Massey said a warning is issued when two case examiners decide it is appropriate and when the doctor has not disputed the facts.
"We publish the warning - detailing the shortcomings in the care provided - on the online register for all patients and employers to see," he added.
- 26 February 2017