Boy died of acne tablet reaction

A coroner is to raise issues of how drugs are dispensed after the death of a 14-year-old boy from a reaction to taking a single acne pill.

Cardiff coroner Mary Hassell said she would be writing to the Lord Chancellor about the case of Shaun Jones, whose death was "beyond" one in a million.
She found Shaun, from Pontypridd, died "of complications" 12 hours after taking the drug Sebomin.
But this was a different drug to the one his doctor had prescribed.
Afterwards, the family said it was considering civil action against the medical authorities.
Recording her narrative verdict, Ms Hassell said Shaun died "as a result of complications of medical treatment".
She said she had researched the case and found no other recorded idiosyncratic deaths involving the tablet anywhere in the world.
"On that basis, this wasn't a one in a million occurrence, it was beyond that," said Ms Hassell.
"Shaun's reaction to it seems to be random and pretty much unique," she said.
Ms Hassell said she would be writing a report to the Lord Chancellor's office underlining the importance of doctors prescribing drugs and the correct information being supplied with medication.
"I have heard that when Shaun went to the pharmacy, he was given a different drug to the one which the doctor prescribed," she said.
"He was given a drug for the first time without the product information leaflet.
"It would be easy to dismiss it as the error of an individual but that would be too easy.
"I know that no system is foolproof and will catch everything but it may be strengthened to catch a little more."
Six foot (1.83m) Shaun, who "excelled at rugby", had previously used a lotion to treat his spots but went to the doctor after hearing his friends had been given medication for acne, the inquest heard.
After being given a prescription, he went to his local pharmacy with his mother Clare, where they were told that drug was out of stock.
Instead pharmacist Lee Coombs gave him Sebomin, which has the same active ingredient.
Mr Coombs said he had not checked with a doctor before changing Shaun's prescription, but said the two drugs were "pharmaceutical equivalents".
He also admitted that, confronted with the same situation again, he would not have dispensed drugs without a leaflet.
The situation arose because only one leaflet is issued per batch of 56 drugs - and as Shaun was prescribed 28, the box was split.
The inquest heard the prescription was only amended by Dr Catherine Taylor, Dr Jones's colleague, on the afternoon of October 21, after Shaun had died.
She said she could not remember if she had been told of the death at the time.
Dr Taylor said she had no concerns "signing off" the changed prescription, as the two drugs were identical.
Mrs Jones noticed there was no safety leaflet included in the box, but thought nothing of that at the time, the inquest heard.
Shaun took the medication with a glass of water just before going to bed at 2230 GMT on October 20 last year at his home in the Rhydyfelin area.
Little more than an hour later, he complained to his parents of shortness of breath and tightness in his chest.
Mrs Jones initially contacted an out of hours GP service but was told no doctor was available, the hearing was told.
When Shaun's condition deteriorated, he was taken to the Royal Glamorgan Hospital, Llantrisant, by ambulance early the next morning.
Despite treatment there, and at the University Hospital of Wales, Cardiff, where he was transferred, Shaun died at 1040 GMT.
In a statement read to the court, his mother Clare Jones said: "My son was fit and healthy. He was 6ft tall and physically very fit.
"He excelled at rugby and trained and played very hard. I'm mystified by his death as is my entire family."
She said she had since conducted her own research into the medication Shaun took.
Mrs Jones said: "Had there been instructions in the box and having read all the information on this drug since, I would have called 999 straightaway and certainly wouldn't have given him the tablet before going to bed."
The whole episode was "extremely painful" for her, Shaun's father Graeme and his younger sister, she said.
Pathologist Dr Edgar Lazka said he could not give a medical cause of death.
His findings were consistent with the theory that Shaun died from an acute reaction to minocycline hydrochloride, the active ingredient in both Sebomin and Minocin, he added.
He said Shaun's face and larynx were swollen, but told the inquest that could have been caused by intensive care treatment.
Dr Lazka said Shaun had the early signs of pneumonia, but it was not severe enough to kill such a "strapping young lad".
Dr Stephen Jolles, consultant immunologist at the University Hospital of Wales, told the inquest that it was possible either the colourings or the active ingredient in the Sebomin tablets Shaun took caused the reaction.
He said it was possible for only "tiny amounts" of a substance to cause a reaction if someone was allergic.

Posted in: health