The coroner found that the regulation, information and treatment for gambling problems at the time of his death were “woefully inadequate” and caused Jack’s death.
The coroner’s conclusion recognised that the state failed in a number of respects in relation to Jack’s death: treatment for gambling problems was insufficient, there was a lack of training for medical professionals and a lack of information available to the public. He said that Jack did not understand that gambling was not his fault and this led to feelings of shame and helplessness. He also found that the Government regulation of gambling did not prevent Jack from gambling despite clearly and obviously being addicted.
The coroner observed that there continue to be significant gaps in treatment and information, and in particular warnings are still insufficient, there is a lack of training for GPs and that, despite young people being most at risk from gambling, there is little information for school children on the subject. As a result of these outstanding issues, which present a risk of further deaths, the coroner will make a prevention of future deaths report addressed to the Department for Education, the Department of Health and Social Care and the Department for Culture, Media and Sport. This is due to be sent to the government on Monday 7 March 2022.
Following the inquest’s conclusion Liz and Charles Ritchie said:
“The coroner has ruled that woefully inadequate state failings have led to Jack’s death. Gambling was the root and trigger of Jack’s death – the court heard that it took hold of a happy healthy 17-year-old child and killed him.
“This inquest is about justice for our Jack. Jack died wrongly believing he was the problem. He was abused by parasitical gambling companies who create a deadly disorder for profit and then blame the victims, saying they should have gambled ‘responsibly’.
“We know that Jack was not the problem and in our grief we are also victims of a predatory industry and a collusive government.
“In this inquest we sought justice not only for our beautiful, kind Jack but also for all the others who are lost to the families who love them.
“Jack’s inquest revealed the link between gambling and suicide has been known for years but thousands of deaths later real change is yet to happen.”
Merry Varney, solicitor at law firm Leigh Day representing the Ritchie family, added:
“Jack was a warm, lively and bright young man loved by friends and his family. The Coroner accepted the undisputed evidence that Jack developed a gambling disorder in the years before his death, having started gambling in sixth form. The Coroner found his GP and the services he was referred to lacked the skills and training to identify his gambling disorder and offer Jack appropriate treatment, as well as a system of regulation which was woeful.
“The evidence also exposed how the current system for funding treatment, research and information, which is reliant on a funding from the gambling industry, has left significant gaps in available treatment for those who develop gambling problems. All this in a society where gambling is advertised widely despite experts believing that some gambling products are as addictive as Class A drugs. The wide ranging and damning findings of the Coroner today must be acted upon by government to prevent other lives being ruined and families bereaved by gambling.”
Will Prochaska, the CEO of Gambling with Lives, the charity Liz and Charles Ritchie co-founded after Jack’s death to support other families bereaved by gambling-related suicide, said:
“Government departments knew about the high suicide risk but failed to adequately regulate the industry, failed to warn the public of the risk, and failed to put proper treatment in place. Instead, they delegated responsibility for protecting the public to gambling-industry-influenced charities.
“The coroner heard that gambling disorder is caused by dangerous gambling products, not by personal failings. Of the estimated 1,227 gambling related suicides since 2018 in England, the Gambling Commission has investigated just 8, showing little concern about the deaths caused by the products they licence.
“It is appalling that the Ritchie family have had to fight the government’s lawyers to bring these issues to light. They’ve done it for the son they’ve lost, and for the growing number of bereaved families. Every day someone takes their life because of gambling products, but the Gambling Act review has seen delay after delay. The government must now act urgently to stop the deaths.”
Jack, 24, died on 22 November 2017 in Hanoi, Vietnam, where he had been living and working as an English teacher. The inquest into his death, held at Sheffield Town Hall between 21 February 2022 and 4 March 2022, heard that Jack, who began gambling aged 17, had been gambling heavily on 2 days before his death and left a note for his family which indicated that gambling was central to his decision to end his life.
Jack’s parents, Liz and Charles Ritchie, told the inquest that they believe gambling killed their son. They believe he was suffering from an undiagnosed gambling disorder and that his death could have been avoided if they and Jack and health professionals whom Jack reached out to had been provided with the information to understand the potentially lethal dangers of gambling and training to recognise his gambling disorder and offer effective treatment.
Liz and Charles told the inquest that they believed that Jack had blamed himself for his gambling and that this was strongly contributed to by the narrative widely propagated by the gambling industry and others that problems with gambling are the result of a lack of personal responsibility, rather than the psychological effects of gambling products. Jack’s feelings of guilt were also apparent from his suicide note, and his parents explained that they want justice for Jack, for him to know it was not his fault and that he was suffering from a recognised mental health illness.
The inquest heard evidence from The Department of Media Culture and Sport (DCMS), The Department for Health and Social Care (DHSC) the Gambling Commission, GambleAware and GamCare relating to the regulation of gambling and the information and support available for those with gambling problems.
Jonathan Marron, director general of the new Office for Health Improvement and Disparities at DHSC, told the court that he did not think there was any dispute about an association between gambling and suicide but admitted that there is still a lack of clear data available about the number of gambling-related suicides in the UK. He said that a recent Public Health England review suggested an average of 409 people die in England each year as a result of gambling-relate suicide.
Sarah Gardner, the Deputy Chief Executive of the Gambling Commission, accepted in evidence that the progress that has been made in addressing gambling-related suicide has been ‘disappointing’.
Zoe Osmond, Chief Executive of the charity GambleAware, which is supposed to work to reduce gambling harms and is funded by voluntary donations from the gambling industry, admitted at the inquest that some academics will not work with GambleAware because of its links to the industry.
The Inquest heard expert evidence from mental health professionals Dr Mike McPhillips and Dr Matt Gaskell that the treatment which Jack received for his gambling disorder was insufficient and that this contributed to his death.
Jack began gambling in his school lunch breaks at the age of 17, with a group of friends. The Inquest heard evidence that Jack had a significant win soon after he started gambling, and Dr Matt Gaskell told the court that such a win can be a trigger to the development of gambling disorder. From this point on, Jack continued to gamble regularly. Jack spoke to his parents about this and tried to stop gambling and sought help on numerous occasions. This included self-excluding from local betting shops when he was 17 and buying blocking software for his computer to prevent access to gambling sites.
In mid-2013 Jack went to see his GP and mentioned his gambling but was told he had an addictive personality that he would have to learn to live with. It was noted he had depressed mood but gambling disorder was not diagnosed.
He visited his GP again in 2015 and 2016, when he began to issues of sleeplessness and anxiety which his parents thought were associated with the stress of his new job. He was diagnosed with an anxiety disorder and was signed off work. Gambling was often thought of by others as Jack’s way of coping with stress and anxiety, rather than the cause of the stress and anxiety, something which Liz and Charles believe would have been recognised sooner if there had been more information available to them and to Jack, and more information and training for the healthcare professionals who Jack saw.
Following an incident in February 2016, when Jack rang his mum and told her he was feeling suicidal after a period of intense gambling, he continued to try to get help, with the support of his family. This included seeing his GP, sessions with a therapist, attending group therapy sessions and a Gamblers Anonymous group. The Inquest heard evidence from Jack’s GP and two therapists who treated Jack that they had little or no training in relation to gambling disorder and little or no understanding of the risks associated, in particular the high suicide risk, and the specialist treatment available at the time.
Liz and Charles told the inquest that they would have handled things differently if they had been provided with information about the dangers of gambling, the addictiveness of some gambling products, gambling disorder and the known associated risk of suicide, and if Jack had been diagnosed.
At the end of 2016, Jack left his job and went to volunteer in Kenya for three months. He then decided to train to teach English as a foreign language and got a job teaching in Hanoi, starting in August 2017. He seemed much happier with this new direction and his family assumed he had stopped gambling and had overcome the problems he had previously experienced. However, from the bank records they obtained after his death, they now know that he gambled on a couple of occasions (with online gambling operators based in the UK) after moving to Vietnam.
Jack was in regular contact with his family while in Hanoi and seemed to be very happy, which was confirmed by his housemates in Hanoi. However, on 19 November 2017 he e-mailed his parents to say that he was having a bad time and was thinking about returning home for a while. His parents had a lengthy video call with Jack and discovered he had been gambling again and had reached his overdraft limit. They offered to pay off his debt and stayed on the phone while he bought and installed gambling blocking software. Jack seemed to become happier as the call went on and decided he wanted to stay in Vietnam after all. He spoke to his parents over the next two days and told them he was feeling better and spending time with his friends, which was again confirmed by his friends in Hanoi.
On 22 November 2017, Liz and Charles received an email from Jack which said that the blocking software had not been installed properly and he had gambled again and was now “past the point of controlling himself”. Jack’s parents were extremely concerned for his safety and immediately set about contacting him and his friends in Hanoi. Tragically, by the time Jack’s friends in Hanoi had worked out where he was and tried to find him, he was already dead.
Liz and Charles Ritchie are represented by Leigh Day partners Merry Varney and Nichola Marshall, as well as Dan Webster, a trainee solicitor. Their barristers are Paul Greaney QC, of New Park Court Chambers, and Jesse Nicholls, of Matrix Chambers.