Open verdict in death of Cheltenham College pupil
A coroner has expressed concern at the way a prestigious public school cares for pupils in crisis following the case of a boy who died after taking an acne drug that has been blamed for causingdepression.
The parents of 16-year-old Jack Bowlby, who was found with a ligature around his neck, also criticised Cheltenham College for the way it acted after the teenager expressed "very dark thoughts".
Jack, the nephew of former champion racehorse trainer and novelist Jenny Pitman, was discovered dead in his room at the school in Gloucestershire, where he was a boarder, in October last year.
The inquest in Cheltenham heard that he was prescribed Roaccutane in December 2011 by consultant dermatologist James Milne. He was originally told to take two tablets – a dose of 40mg – a day and this was upped to three pills in January 2012. Within days Jack was complaining of having "very dark thoughts", the inquest was told. Staff at Cheltenham College did not consult Milne but reduced the dose to one tablet.
According to the Medicines and Healthcare products Regulatory Agency (MHRA), which regulates medicines in the UK, users of Roaccutane – also known as isotretinoin – have reported depression, aggravation of existing depression, aggressive tendencies, anxiety, and changes in mood, though it stresses such reports are rare. It says suicide attempts and suicide have been reported very rarely (in one in every 10,000 patients or fewer).
When Jack returned to school in September after the summer break, he told a matron he had not been taking the medication but wanted to start it again. He took his first pill on 11 October. At around 7am the next day, boarders in his college house discovered his body in his bedroom.
Milne told the inquest he had stressed the importance of being contacted if any side effects developed. But he said he was not told that Jack had spoken of dark thoughts, adding: "It is quite disturbing. I was unaware. If I had been informed that he had dark or suicidal thoughts I would have wanted to stop the drug immediately and for him to see a psychiatrist."
The inquest heard that Jack had argued with his parents in September 2012, two weeks before his death – something that was "out of character". His final text to his mother had read: "That's you and me finished." The evening before he was found dead he had been researching suicide notes online – though he did not leave one.
Tom Osbourne, deputy assistant coroner for Gloucestershire, recorded an open verdict, saying there was "insufficient evidence" to prove what caused Jack's death. "It may have been an accident, it may have been suicide, it may have been Roaccutane. There is insufficient evidence."