Following the passing of a “anxious” 17-year-old A-level student, a coroner has issued a warning over the absence of face-to-face GP visits.
An inquest heard that Sean Mark, who was worried he could have ADHD, said he felt “fobbed off” after only obtaining a phone consultation from a doctor and then being sent to websites for support rather than seeing a doctor in person.
The adolescent, who referred to himself as a “anxious paranoid mess,” was discovered hanged in his bedroom at home in December 2021, only one day after submitting an electronic consultation form with the health agency. Finishing Sean’s investigation,
Rosamund Rhodes-Kemp, the coroner for the Hampshire region, expressed concern about “gaps that are forming” in mental health services and expressed hope that this wouldn’t happen to another adolescent.
Following his case, his parents, Kevin and Suzanne Mark, both former Royal Navy sailors, are urging GP offices throughout the nation to prioritise face-to-face consultations between parents and medical experts.
I don’t see how somebody could evaluate someone’s mental health over the phone, Ms. Rhodes-Kemp remarked. It was tricky given the limitations of the epidemic, but diagnosing someone over the phone is difficult.
“We’ve gotten ourselves into a little bit of a jam.” Due to a lack of general practitioners, gaps are expanding and patients are generally unhappy with the situation.
“[Sean] had no in-person appointments. We really hope that another 17-year-old won’t experience this, and that they will be given a face-to-face appointment.
“I don’t know whether this might have been averted if he had that face-to-face. But it definitely would have been beneficial.
According to testimony given at the Portsmouth Coroner’s Court, A-Level student Sean, of Gosport, Hampshire, was a “cheeky and cheerful youngster” who was “loving and kind.”
The court was informed that he had battled anxiousness and thought he could have ADHD. After finding it difficult to muster the will to complete college homework, the kid had informed his father Kevin that he wanted to be tested.
Sean reportedly made his first contact with the neighbourhood Willow Group GP office in August of last year. He reportedly had a phone appointment with a doctor who advised him to look for guidance online.
He completed many NHS e-consults over the next months, but his situation remained unchanged and he was unable to get the face-to-face meeting he desired.
According to the inquiry, Sean, who wanted to major in economics, got a score that classified him as having mild depression and indicated that he might benefit from talking therapy.
‘From my own personal experience, we had a lot of teens who would arrive, either individually or with family, with issues surrounding low mood or anxiety,’ said Dr. Robin Harlow, a partner at the clinic.
The inquiry heard that the waiting list for Hampshire’s NHS talking therapy programme, iTalk, was six to eight months long.
According to testimony given at the hearing, Sean acknowledged in an email exchange from last October that he had exaggerated how terrible his mental condition had been during the first phone call.
He said that in order to “start moving on with his life” and stop being a “anxious paranoid mess,” he wanted to get evaluated for any illnesses he suspected he could have, such as ADHD.
Sean’s parents discovered him dead on December 4 of last year after he had been untreated for two months.
He had submitted another online NHS form pertaining to his health the day before.
In his testimony during the court, Mr. Mark, 58, who is now employed by the government, said, “I am grieved by the death of my son who was such a nice, bright and compassionate guy.”
There was enough doubt that Sean had meant to take his own life for Ms. Rhodes Kemp to record a judgement of death by misadventure at the conclusion of the inquest.
The coroner discussed the potential for disclosing private information to the parents of vulnerable young people while also criticising the present NHS waiting times and lack of continuity of treatment.
Despite the fact that their parents are still legally responsible for them until they become 18, a patient under the age of 18 who comes to a doctor with mental health difficulties currently has enforceable patient confidentiality.
Speaking after the hearing, Mr. and Mrs. Mark expressed their desire to reform GP offices “up and down the nation” in order to leave a lasting legacy for their son.
Mrs. Mark expressed optimism that “there is a potential benefit” to this story and urged other parents to “engage with their children” after spearheading changes in mental health care in their own surgery.
Chief Petty Officers in the Royal Navy, Mr. and Mrs. Mark have stated that they want to stop something similar from happening to another family.
Everyone agrees that more could have been done, but Mrs. Mark, 49, who is now employed as an instructor at the navy base HMS Collingwood, said: “It doesn’t bring my son back.” Sean was lost.
However, we wanted to do what we could to make a difference rather than become enraged.
Mr. and Mrs. Mark visited the surgery on December 29 of last year for “quite a frank discussion.”
Mrs. Mark said of the meeting’s conclusion: “We don’t hold anybody accountable.” Nobody is flawless. They have been excellent.
They haven’t simply been going through the motions; they’ve been thinking a lot about what they can do better.
We have been collaborating with them to bring about improvement. It’s quite simple to criticise government agencies and complain about everyone else.
The most important thing to us is to attempt to save another family from finding themselves in a similar circumstance, if at all possible.
You can either get enraged or ask, “What can I do to have a good impact?” and that is what we have done.
Less than two weeks following their first meeting, Mr. and Mrs. Mark attended a follow-up meeting where they were shown the modifications that had already been made as well as the future plans to address their concerns.
The Willow Group practise now makes sure that there is continuity of treatment and that patients are served by the same GP unless there is an urgent situation, giving priority to in-person consultations.
The fourth and last Great South Run will benefit Papyrus UK, a charity that works to prevent juvenile suicide, according to Mrs. Mark.
“It’s something I can do to make a little difference,” she said.
whether The Willow Group may serve as an inspiration for further transformation. A really terrible scenario has turned out for the better, Mrs. Mark added. I hope it can occur all around the nation.
“There has been optimism, and I want that to be something my kid remembers,” I said.
We’ll keep working with The Willow Group to support good change in any way we can.