An inquest has heard that the nephew of former chamption race horse trainer Jenny Pitman killed himself while taking the controversial acne drug Roaccutane, which has previously been linked to suicides.
Talented show jumper Jack Bowlby, 16, hanged himself at the prestigious Cheltenham Collage after experiencing 'very dark thoughts' while taking the medication.
The hearing was told that the day before he died, Jack had decided to start taking Roaccutane again, having previously come off it after a family friend raised concerns about its safety.
The NHS prescribes the drug for severe acne, despite campaigners calling for it to be banned.
Jack first started taking the medication in December, 2011, and had his dose increased from 40mg to 60mg after a month.
He then complained to his school matron Tracey Hopson that he was having 'very dark thoughts'.
Ms Hopson told Gloucester's Coroner's Court that she had been 'worried about how dark the thoughts were' and that they decided to reduce Jack's dose, but without informing his dermatologist, James Milne.
Dr Milne told the court that he would have stopped Jack from taking the drug 'immediately' and referred him for counselling had he known.
On the reduced dose Jack continued his studies and sat his GCSEs, and said in September 2012 that he had stopped taking the drug altogether. He then asked the school matron to start taking it again on October 1.
The Telegraph reports that Ms Hopson said she had outlined in red to call the medical centre after Jack went back on the medication, 'but it was a particularly busy day' and so she 'didn't get round to it'.
A fellow pupil and boarder at Cheltenham, Jack Severn, found Jack's body in his room at 7am on October 12, the day after he took his first tablet.
He told the inquest that he had been made aware that Jack had recently argued with his mum and dad, and that he was disappointed about the results of a riding show, but that he did not have any concerns for his welfare and that he was not bullied at school.
The hearing continues, and Jack's parents are due to give evidence today. Jack's mother is the sister of Jenny Pitman.
Roche, who make Roaccutane, deny that there is a causal link between the drug and depression or suicide.