A 17-year-old student who said he felt "fobbed off" at being unable to have a face-to-face GP appointment was found dead in his bedroom four months after he first asked to see a doctor, an inquest heard.
Sean Mark, who was concerned he was suffering from ADHD, was unhappy after receiving only a phone consultation where he was told to fill out online forms, and a coroner has now highlighted the dangers of a lack of in-person appointments with GPs.
His parents - former Royal Navy sailors Kevin and Suzanne - are calling for changes to be made generally at GP surgeries after their son's practice agreed to prioritise face to face meetings following his case.
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.
She 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, was a "cheeky and bubbly child" who was "kind and caring", Portsmouth Coroner's Court heard.
But he had struggled with anxiety and, believing he might have ADHD, he 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.
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".
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."
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."
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