A coroner has expressed concern at the difficulty of getting face-to-face appointments with GPs and other health professionals after a 17-year-old boy suffering from mental health problems was found dead.
Sean Mark, who described himself as an “anxious paranoid mess”, was desperate for help but felt “palmed off” when he asked for assistance, an inquest heard. He was found dead in his bedroom four months after a phone consultation with a GP and before he had spoken to anyone in person about his concerns.
The area coroner, Rosamund Rhodes-Kemp, recorded a verdict of death by misadventure, saying she could not be sure Sean had intended to kill himself.
She said: “I don’t know how anyone can assess someone’s mental health over the phone. 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. Whether – had he had that face to face – this could have been avoided, I don’t know. But it certainly would have been helpful. Sean had bravely contacted the GP surgery about his problems. He was desperate for help. There was no doubt Sean was frustrated by all of that and felt palmed off.”
Rhodes-Kemp added: “I am aware of the problems facing GPs. I’m sure all of this was exacerbated by lockdown restrictions.”
Portsmouth coroner’s court heard that Sean, the son of two naval officers from Gosport, Hampshire, was a “kind and caring” A-level student who struggled with anxiety and believed he might have ADHD. The hearing was told Sean first contacted the Willow Group of GP practices in Gosport 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 digital consultations and it had been noted that he had moderate depression and would benefit from talking therapy. However, italk, Hampshire’s NHS talking therapy service, had a six- to eight-month waiting list, the inquest heard.
In an online consultation last October, Sean admitted that in his original phone conversation he had underplayed how bad his state of mind was. He said he wanted to be tested for conditions he thought he may have, such as ADHD, so he could stop being an “anxious paranoid mess”.
On 4 December, still not having seen a healthcare professional and the day after completing another online NHS form, Sean was found dead by his parents.
Dr Robin Harlow, clinical director of the Willow Group, said it had increased the number of face-to-face meetings. When told that Sean felt palmed off, he said: “I would want him to be seen face to face at the second time, if not the first time. We have seen a lot more face-to-face appointments since then.”
Speaking after the inquest, Sean’s mother, Suzanne Mark, said: “It is agreed by everyone that more could have been done, but it doesn’t bring back my son.”
She said the family believed the surgery was listening to them and was trying to make changes.
In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.
