A fit and healthy 14-year-old rugby player died 12 hours after taking treatment for acne, an inquest heard today.
Shaun Jones, described by his mother as "vain" about his appearance, saw his doctor about spots on his back and shoulders after learning his friends had been given medication to deal with similar problems.
The 6ft schoolboy, of Rhydyfelin, near Pontypridd, South Wales, who had previously used Clearasil to treat the spots was diagnosed with mild acne and given a prescription, Cardiff Coroner's Court heard.
But when he went to his local pharmacy with mother Clare, he was told that drug was out of stock. Shaun and his mother were told the pharmacist had spoken to the doctor, and he could be given different tablets which were exactly the same as the other medication.
Mrs Jones noticed there was no safety leaflet included in the box, but thought nothing of that at the time.
Shaun took the medication with a glass of water just before going to bed at 10.30pm on October 20 last year.
Little more than an hour later, he complained to his parents of shortness of breath and tightness in his chest.
Mrs Jones initially contacted an out of hours GP service but was told no doctor was available.
When Shaun's condition deteriorated, he was rushed to the Royal Glamorgan Hospital, Llantrisant, by ambulance in the early hours of the next morning.
Despite treatment there, and at the University Hospital of Wales, Cardiff, where he was transferred to, Shaun died at 10.40am on 21 October.
Doctors at the University Hospital of Wales believe an "idiosyncratic reaction" to the acne medication could have caused his death.
In a statement read to the court, Mrs Jones said: "My son was fit and healthy. He was 6ft tall and physically very fit.
"He excelled at rugby and trained and played very hard.
"I'm mystified by his death as is my entire family."
She said she had since conducted her own research into the medication Shaun took.
Mrs Jones said: "Had there been instructions in the box and having read all the information on this drug since, I would have called 999 straightaway and certainly wouldn't have given him the tablet before going to bed."
The whole episode was "extremely painful" for her, Shaun's father Graeme and his younger sister, she said.
Shaun was described by James Williams, his head teacher at Hawthorn High School, Pontypridd, as an "extremely popular student" who "excelled" in playing rugby for his school, village and district teams.
In a statement read to the inquest he said: "He'd everything to live for and would have been a credit to himself, his family and the school.
"There is no reason for him not to have been not only an excellent rugby player but a valuable member of the community."
Dr Stephen Jolles, consultant immunologist at the University Hospital of Wales, said it was possible either the colourings or the active ingredient in the Sebomin tablets Shaun took caused the reaction.
He said it was possible for only "tiny amounts" of a substance to cause a reaction if someone was allergic.
The drug Shaun was originally prescribed, which was out of stock at the pharmacy, was Minocin, the inquest heard.
Dr Rim Al-Samsam, consultant paediatrician at the hospital, said she did not believe an infection or anaphylactic shock had caused Shaun's death.
Pathologist Dr Edgar Lazka said he could not give a medical cause of death.
His findings were consistent with the theory that Shaun died from an acute reaction to minocycline hydrochloride, the active ingredient in both Sebomin and Minocin, he added.
He said Shaun's face and larynx were swollen, but told the inquest that could have been caused by intensive care treatment.
Dr Lazka said Shaun had the early signs of pneumonia, but it was not severe enough to kill such a "strapping young lad".
Toxicologist Simon Elliot heard Shaun vomited three times after taking Sebomin in an orange capsule, and said that would have limited the amount of medication released into his system.
He found no other drugs, or alcohol, in the teenager's body.
Dr Christopher Jones, Shaun's family doctor who prescribed the acne treatment, spoke of his sadness at the teenager's death, describing him as a "robust, full-of-life young man".
Dr Jones, a partner at the Taff Vale Surgery in Rhydyfelin, told the inquest that Shaun complained about spots on his back and shoulders, and added: "He volunteered that he was proud of his body."
There was no acne visible on Shaun's face, Dr Jones said.
He diagnosed the acne as "mild to moderate", and suggested Shaun take Minocin, an antibiotic, as topical treatments were difficult to apply to the back area.
Shaun asked the doctor if the drug would remove his spots, to which he was told: "It's not likely to get rid of the spots you've got, but it will prevent any more, and perhaps get rid of some of the redness."
He was warned of indigestion and aching joints, but no other potential side-effects.
Dr Jones wrote the prescription by hand after the 10-minute consultation, choosing Minocin as it was a drug he was familiar with.
He said the pharmacist had not contacted him to say they had run out of the drug.
When asked by Coroner Mary Hassell if he would have been happy for an alternative to be dispensed, he said: "I would have to be happy that it was the same drug, the same active ingredient.
"I would also want to know that it was also a slow-release, once-daily dose."
The doctor said that, in hindsight, he would also have asked if the drug had the same side-effects.
He was told of Shaun's death the next afternoon, and visited the family at their home.
He said: "It was one of the hardest knocks on the door I have ever done.
"I went in the house, and it was full of grief. There were many members of his family, and extended family, there, clearly devastated and inconsolable."Reuse content