Advising with empathy and experience

Boy, 17, found dead after seeking mental health help 'had not seen GP in person'.


A coroner has expressed concern at the difficulty of getting face-to-face appointments with GPs and other health professionals after a teenage boy suffering from mental health problems was found dead.

Sean Mark, 17, who described himself as an “anxious paranoid mess”, was desperate for help but felt “palmed off” when he asked for assistance, Portsmouth coroner’s court 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.

Hampshire and Cambridgeshire coroner, Rosamund Rhodes-Kemp, recorded a verdict of death by misadventure, saying she could not be sure Sean Mark 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 and there is a lot of dissatisfaction from patients.

“Sean never had a face-to-face appointment. Whether, if he had that face-to-face appointment, 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. I am aware of the problems facing GPs. I’m sure all of this was exacerbated by lockdown restrictions.”

The inquest 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 he had first contacted the Willow Group of GP practices in Gosport in August 2021 and had a phone consultation with a doctor who recommended he seek advice online.

During 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, the inquest heard that Hampshire’s NHS talking therapy service, italk, had a six-to eight-month waiting list.

In one online consultation, Sean Mark 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 might have, such as ADHD, so he could stop being an “anxious paranoid mess.”

On 4 December 2021, having still not seen a healthcare professional and the day after completing another online NHS form, he was found dead by his parents.

Clinical director of the Willow Group, Dr Robin Harlow, said it had increased the number of face-to-face meetings. When told that Sean Mark 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.