Jack Bowlby: Roaccutane 'may have led to student's death'
An acne drug may have contributed to the death of a 16-year-old student, an inquest has heard.
Jack Bowlby was found dead in his room at Cheltenham College on 12 October.
Gloucester Coroner's Court heard he experienced "very dark thoughts" and violent mood swings after taking Roaccutane to clear his skin.
Coroner Tom Osbourne said there was "insufficient evidence" to prove his death was caused by the drug and recorded an open verdict.
Mr Osbourne said Jack died as a result of neck compression by a ligature.
Speaking at the inquest, Dr Graham Mould, a consultant pharmaceutical forensic toxicologist, said the risk of side effects from taking Roaccutane was highest within six months of finishing treatment and Jack was four months into that period at the time of his death.
Drug 'probably' linked
Jack had stopped taking the treatment for a period but asked his college matron Tracey Hopson to start retaking the drug last October.
College medical records show he took a one capsule dose at 13:00 GMT on 11 October, the day before he was found dead.
Dr Mould said: "I have to ask myself if he had not taken Roaccutane over the last six months, would he have taken his life? I suppose I have to say that probably not."
He said statistics suggested there was a one in 10,000 risk of developing suicidal thoughts while taking Roaccutane.
The inquest heard Jack had first been prescribed the drug by Dr James Milne at the Nuffield Health centre in Cheltenham in December 2011.
Dr Milne prescribed an initial dose of two capsules, which was increased up to three capsules in January 2012.
Three days later, Jack told the college matron he was experiencing "very dark thoughts" and considering suicide.
He was taken to his home in Wantage, Oxfordshire, by his parents and his dose of Roaccutane was reduced to one capsule a day.
Dr Milne had advised Jack and Mrs Hopson that he should be informed immediately if any side effects were experienced but he was not notified and the incident was not entered in Jack's medical notes at Cheltenham College.
He returned to the school three days later and appeared "back to normal".
Dr Milne previously told the inquest if he had been informed of the development, he would have immediately stopped Jack's treatment and referred him to a psychiatrist.
Recording an open verdict, Mr Osbourne said he could not be sure that Jack intended to take his own life and said there was "insufficient evidence" to prove his death was caused by Roaccutane.
He said: "Jack was a hugely popular, hard-working young man and in addition, a very talented horseman who probably had, as everybody perceived, a glittering career in front of him.
"Sadly that is no longer the case."
He said he would consider writing a report under Rule 43 of the Coroner's Rules recommending a specific suicide prevention policy or a crisis policy, which Cheltenham College does not have.
In a statement, Jack's family said they "hoped out of this tragedy some good may come".
They said they felt Roaccutane "may have played a part in Jack's death", and said patients and their parents should be "very aware of the possible risks".
Dr Alex Peterken, headmaster of Cheltenham College, said Jack's death came as "a bolt from the blue".
He said following the initial episode of side effects in January 2012, Jack's behaviour at college gave "no further cause for concern" and he was making "good academic progress in the new school year".