A coroner said yesterday a healthy 14 year old rugby player died 12 hours after he took an acne pill. Cardiff coroner Mary Hassell said she would write to the Lord Chancellor about the case of Shaun Jones, from Pontypridd whose death was "beyond" one in a million and express concerns that the pharmacist gave 14-year-old Shaun Jones an alternative to the tablets the doctor had prescribed.

Hassell said Shaun died "of complications" 12 hours after taking the drug Sebomin, which was not the drug prescribed by his doctor and also because the drugs he received did not come with an information leaflet.

She added that she had found no other recorded idiosyncratic deaths involving the tablet anywhere in the world in her research. "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. After the hearing Shaun's father, Graeme Jones, said "lessons must be learned" following Shaun's death, and said they were considering civil action against the medical authorities.

Shaun a six foot (1.83m) tall boy 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. He was prescribed the acne medication Minocin but as it was out of stock pharmacist Lee Coombs gave him Sebomin instead.

Coombs said the two drugs were "pharmaceutical equivalents" and had not checked with a doctor before changing Shaun's prescription. No prescription leaflet was given as the box was split in half and Shaun's mother Clare who was with him thought nothing of it.

Shaun took a tablet with a glass of water just before going to bed on 20 October and a little over an hour later he complained to his parents of shortness of breath and tightness in his chest. Clare initially contacted an out of hours GP service but was told no doctor was available and 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.

Doctors at the hospital believe his death could have been caused by an "idiosyncratic reaction" to the acne medication. Pathologist Dr Edgar Lazka suggested Shaun may have died from an acute reaction to the active ingredient found in Sebomin and Minocin.

Shaun's mother Clare Jones in a statement to the court 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 added, "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."

Hassell said, "I look at Shaun's family and I know nothing I say will be able to make sense of how a fit and healthy 14-year-old boy is completely fit and healthy one day and dead the next."

The coroner said that Shaun's death was the first of its kind in the world. But she said she would write to the government to take note of how important it was that "doctors prescribe drugs and doctors make amendments and patients receive drugs with the correct information attached".

She said, "I have heard that when Shaun went to the pharmacy, he was given a different drug to the one which the doctor prescribed. 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."