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Shaun Jones, of Rhydyfelin, near Pontypridd, South Wales, saw his doctor about spots after learning his friends had been given medication for their acne.
The 6ft schoolboy was diagnosed with mild acne and given a prescription for Minocin, Cardiff Coroner’s Court heard.
But when he went to a pharmacy with mother Clare, the drug was out of stock.
They were told the pharmacist had spoken to the doctor, who said Shaun could be given an alternative.
Mrs Jones noticed there was no safety leaflet in the box for the replacement, called Sebomin, but thought nothing of it.
Shaun took the drug with a glass of water at 10.30pm before going to bed. An hour later he complained 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.
Later she called 999 and he was taken to hospital by ambulance.
Despite treatment at Royal Glamorgan Hospital, Llantrisant, and the University Hospital of Wales, Cardiff, he died at 10.40am on October 21.
In a statement read to the court, Mrs 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.”
The statement continued: “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.”
Dr Stephen Jolles, consultant immunologist at the University Hospital of Wales, said Shaun could have suffered an “idiosyncratic reaction” to either the colourings or the active ingredient in the Sebomin tablets. It was possible for only “tiny amounts” of a substance to cause a reaction if someone was allergic, he said.
The inquest continues.
Telegraph.co.uk