Coroner issues warning over lack of face-to-face GP appointments after ‘anxious’ A-level pupil, 17, with ADHD was found hanged in his room because he felt ‘fobbed off’ by telephone medic who told him to look online for help
- Sean Mark – who was concerned he was suffering from ADHD – felt ‘fobbed off’
- He had only had a phone consultation and pointed to websites for help by doctor
- Teen, 17, was found hanging in a bedroom at home just a day after e-consult form
- Coroner has warned of ‘gaps that are appearing’ in mental health care
- For support call the Samaritans on 116 123 or go to www.samaritans.org
A coroner has issued a warning over the lack of face to face GP appointments following the death of an ‘anxious’ 17-year-old A-level pupil.
Sean Mark – who was concerned he was suffering from ADHD – said he felt ‘fobbed off’ after receiving only a phone consultation from a doctor before being pointed to websites for help rather than seeing a medic in person, an inquest heard.
The teenager, who described himself as an ‘anxious paranoid mess’, was found hanging in his bedroom at home in December 2021 just a day after completing a health service ‘e-consult’ form.
Concluding Sean’s inquest, Hampshire area coroner Rosamund Rhodes-Kemp warned that ‘gaps that are appearing’ in mental health care and hoped that this would not happen to another teenager.
His parents – former Royal Navy sailors Kevin and Suzanne Mark – are also calling for changes to made in GP surgeries across the country to prioritise face to face meetings between parents and healthcare professionals following his case.
Sean Mark – who was concerned he was suffering from ADHD – felt ‘fobbed off’ after receiving only a phone consultation and then being pointed in the direction of websites rather than seeing a medic in person, an inquest heard
Ms Rhodes-Kemp said: ‘I don’t know how anyone can assess someone’s mental health over the phone. With the pandemic’s restrictions it was difficult – but diagnosing someone over the phone is challenging.
‘We have got ourselves in a bit of a muddle. We have ended up in a situation where we don’t have enough GPs […] gaps are growing – and there is a lot of dissatisfaction from patients.
‘[Sean] never had a face to face appointment. We hope very much this wouldn’t happen to another 17-year-old – and they would get the face to face appointment.
‘Whether, had he had that face to face, this could have been avoided – I don’t know. But it certainly would have been helpful.’
A-Level student Sean, from Gosport, Hampshire, was a ‘cheeky and bubbly child’ who was ‘kind and caring’, Portsmouth Coroner’s Court heard.
However, he had struggled with anxiety and believed he might have ADHD, the court was told. The teenager had told his father Kevin he wanted to get tested after struggling to motivate himself to finish assignments from college.
The hearing was told Sean first contacted the local Willow Group GP surgery in August last year and had a phone consultation with a doctor who recommended he seek advice online.
Over the next few months he carried out a number of NHS e-consults, but was still no better off and had been unable to get the face to face appointment he wanted.
The inquest heard Sean – who had ambitions to study economics at university – had recorded a score which categorised him as having moderate depression and noted that he would benefit from talking therapy.
Dr Robin Harlow, a partner at the practice, said: ‘From my own personal experience, we have a number of teenagers that would be presenting, either themselves or with family, with concerns regarding low mood or anxiety – boys included.’
However, iTalk, Hampshire’s NHS talking therapy service, had a six to eight month waiting list, the inquest heard.
The hearing was told that in an e-consult last October Sean admitted that in his original phone conversation he had underplayed how bad his state of mind was.
The teenager, who described himself as an ‘anxious paranoid mess’, was found hanging in his bedroom at home in December 2021 just a day after completing a health service ‘e-consult’ form
He revealed his desire to be tested for conditions he thought he may have, such as ADHD, so he ‘could start getting on with his life’ and stop being an ‘anxious paranoid mess’.
Two months later, and still not having seen a healthcare professional, Sean was found dead by his parents on December 4 last year.
The day before he had completed another online NHS form regarding his health.
Mr Mark, 58, who now works for the civil service, told the hearing: ‘I am devastated at the loss of my son who was such a kind, intelligent and caring person.’
Concluding the inquest, Ms Rhodes Kemp recorded a verdict of death by misadventure, as there was sufficient doubt that Sean had intended to take his own life.
The coroner criticised current NHS waiting times and lack of continuity of care whilst also discussing the possibilities of sharing confidential information with vulnerable young persons’ parents.
Currently, an under 18 who presents to a doctor with mental health issues has binding patient confidentiality – despite their parents having legal responsibility until they turn 18.
Speaking after the hearing Mr and Mrs Mark said they are keen to make their son’s legacy a positive one – and initiate changes in GP surgeries ‘up and down the country’.
Having already led changes in mental health care in their own surgery, Mrs Mark is hopeful ‘there is a potential benefit’ to this story and encouraged other parents to ‘engage with their children’.
Mr and Mrs Mark, who were both Chief Petty Officers in the Royal Navy, have said they want to prevent anything like this happening to another family.
Mrs Mark, 49, who now works as an instructor at navy base HMS Collingwood, said: ‘It is agreed by everyone that more could have been done, but it doesn’t bring back my son. We lost Sean.
‘But rather than get angry, we wanted to do what we could to help make a difference.’
Concluding Sean’s inquest, Hampshire area coroner Rosamund Rhodes-Kemp warned that ‘gaps that are appearing’ in mental health care. Pictured: Mountbatten Gallery in Portsmouth where the inquest was held
On December 29 last year, Mr and Mrs Mark met the surgery for ‘quite a frank discussion’.
On the outcome of the meeting, Mrs Mark said: ‘We don’t hold anybody responsible. Nobody’s perfect. They have been very good.
‘All the way through they have been very much about what they can do differently – not just going through the motions.
‘We have been working with them for positive change. It’s very easy to bash public organisations and moan about everybody else.
‘If we can do anything to try to prevent another family from being in a similar situation, that’s the most important thing to us.
‘You can get angry, or you can say ‘what can I do to make a positive impact?’ and that’s what we’ve chosen to do.’
Less than two weeks after their meeting, Mr and Mrs Mark went for a follow up meeting – and were shown changes already implemented and future plans to address the couple’s concerns.
The Willow Group surgery now ensures there is a continuity of care and patients are treated by the same GP unless it is an absolute emergency and face to face meetings are prioritised.
Mrs Mark revealed that she has plans to run her fourth and final Great South Run for Papyrus UK, a prevention of young suicide charity.
She added: ‘It’s something I can do to make a small difference.’
On whether The Willow Group can be an example to spark more change. Mrs Mark said: ‘Good has come out a very very sad situation. Hopefully it can happen up and down the country.
‘There has been positivity and that is something I want in my son’s memory.
‘We will continue to work with The Willow Group to do all we can to assist for positive change.’
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