A controversial acne drug could have contributed to the death of former champion racehorse trainer Jenny Pitman's nephew, an inquest heard.
Talented horseman Jack Bowlby, 16, experienced "very dark thoughts" and violent mood swings after beginning a course of Roaccutane to clear his skin.
He was discovered dead in his dormitory room at the independent school Cheltenham College in Gloucestershire at 7am on October 12 last year.
Experts told an inquest at Gloucester Coroner's Court there was a possibility Jack may not have died if he had not taken the drug.
But Tom Osbourne, deputy assistant coroner for Gloucestershire, said there was "insufficient evidence" to prove that Jack's death was caused by Roaccutane.
Mr Osbourne, who recorded an open verdict, said he was concerned at the way Cheltenham College handled cases of children in crisis.
He is considering writing a report under Rule 43 of the Coroner's Rules recommending a specific suicide prevention policy or a crisis policy, which Cheltenham College does not have.
Jack was prescribed Roaccutane by Dr James Milne at the Nuffield Health centre in Cheltenham, after being referred to the skin specialist by his GP, in December 2011.
Dr Milne prescribed an initial dose of two capsules, which was increased up to three capsules on January 20 2012.
Within three days, Jack told matron Tracey Hopson that he was experiencing "very dark thoughts" and considering suicide.
He was taken back home to Wantage in Oxfordshire, by parents Michael and Mandy Bowlby, and his dose of Roaccutane was reduced to one capsule daily.
Dr Graham Mould, Consultant Pharmaceutical Forensic Toxicologist, said Swedish research appeared to show the risk of side effects from Roaccutane peaked within six months of finishing treatment.
Jack's father Michael Bowlby said he and wife Mandy had not been aware the "dark thoughts" their son experienced in January included suicide.
Statistics suggest there is a one in 10,000 risk of developing suicidal ideation while taking Roaccutane.
Recording an open verdict, Mr Osbourne said he could not be sure that Jack intended to take his own life.
Mr Osbourne recorded that Jack died as a result of neck compression by a ligature.
Watch Ken Goodwin's report here: