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Coroner raises serious concerns about the risk of future deaths to Betfair, the Gambling Commission and Government following Luke Ashton inquest

A coroner has written to Flutter, parent company of Betfair, the Gambling Commission and Lucy Frazer MP, the Secretary of State for Culture, Media and Sport, to raise serious concerns about the risk of further deaths if actions are not taken following the inquest into the death of Luke Ashton. 

Posted on 19 July 2023

The inquest into the death of Luke Ashton, 40, concluded on 29 June 2023 that he died as a result of gambling disorder and a lack of meaningful intervention from Betfair. It is believed that this is the first time this has been recorded in an inquest.
Now, HM Area Coroner Ivan Cartwright has written a Prevention of Future Deaths report, also known as a Regulation 28 report, identifying the following matters of concern:
  1. That Betfair’s player protection tools were and are inadequate to protect a person in Luke’s position and do not amount to any meaningful interaction or intervention;
  2. That Betfair’s algorithm failed to flag Luke as a ‘problem gambler’, despite the increases in time spent gambling and the size of his deposits and losses, because his gambling behaviour was not deemed to be exceptional;
  3. That Betfair appears to judge the extent of its responsibilities to customers solely with regard to industry/regulatory standards, rather than current good or best practice in order to prevent harm.
The report is addressed to the Gambling Commission and the Secretary of State, as well as Flutter, on the basis that they also have the power to take action to prevent future deaths arising from these concerns.

Luke Ashton.
All three organisations are under a duty to respond to the Coroner’s concerns and are required to do so within 56 days. In their responses, they are required to set out the action taken or proposed to be taken in response, including a timetable for action, or to explain why no action is taken in response.
The report has also been copied to GambleAware on the basis that they may find it useful or of interest.
The inquest into Luke’s death heard that, in the weeks leading up to his death, Luke was often spending almost entire days gambling. The inquest heard expert evidence that Luke’s gambling showed significant signs of potential harm in 2019 and 2020, but that indicators of risk increased dramatically in early 2021, when the amounts of time and money which Luke spent gambling, and the intensity of his betting increased significantly.
Professor David Forrest, an expert in interpreting gambling records, told the inquest that during the period in early 2021 it was clear that Betfair should have identified Luke as being someone at high risk of harm and should have considered imposing measures to restrict Luke’s gambling, including potentially by closing his Betfair account.  During the same period, Luke was rewarded by Betfair for his increased betting activity in that he was able to claim an increased free bet and enter a promotion that incentivised further gambling.
The inquest also heard expert evidence from Professor Dame Clare Gerada, President of the Royal College of GPs, that Luke had suffered from a longstanding and pervasive gambling disorder and that this caused his death.
Luke’s wife Annie Ashton said in reaction to the report:
“I believe that all gambling operators should have their safer gambling tools and algorithms assessed by an independent third party in the same way that Professor Forrest was able to do so during the inquest. This would help to advise and implement 'best practice' when spotting those who are showing signs of harm and protecting them from further harm in the future.
“Additionally, there is an urgent need for the Gambling Commission to step up and effectively oversee the markers used to detect harm caused by operators and routinely check that operators are setting the appropriate thresholds developed specifically to show those considered to be at risk, in the real world.
“Betfair gave evidence at the inquest that only 2.1% of its customers received a human interaction in 2021, while around 18% of gamblers have been found to be at risk and this is clearly unacceptable as it led to inadequate interventions. For Luke this was imperative. Failure to intervene should result in licences being removed by the Gambling Commission.”
Dan Webster, a solicitor at law firm Leigh Day, said:
“The Coroner’s Prevention of Future Deaths report makes clear that he was not satisfied by Betfair’s evidence at the inquest that sufficient changes have been made since Luke’s death to prevent further harm. It is a strong statement of the Coroner’s concern that the systems which failed to protect Luke may lead to further deaths if action is not taken. This applies not only to Betfair and Flutter, who clearly have significant lessons to learn, but to the gambling industry as a whole and, crucially, to those responsible for regulating the industry and setting the standards.
“During the inquest, Betfair asserted repeatedly that their ‘safer gambling’ systems complied with regulatory standards and were superior to those of many other operators. The PFD report recognises that, irrespective of whether Betfair complied with regulatory requirements, it is a matter of real concern that no meaningful interaction or intervention was carried out in Luke’s case. As identified by the Coroner, the algorithms used by online operators to identify signs of harm have a crucial role to play, and it is essential that there is adequate scrutiny and oversight of how these algorithms operate to ensure that they protect people from harm. We hope that the government and the Gambling Commission will recognise the importance of the Coroner’s findings and this report and ensure that proposed changes to the system of gambling regulation are adequate to prevent further lives being lost as a result of gambling harm.”


Merry Varney
Court of Protection Human rights Inquests Judicial review

Merry Varney

Merry is a partner in the human rights department and head of the Leigh Day inquest group

Dan Webster (1)
Court of Protection Discrimination Human rights Inquests Judicial review Public law

Dan Webster

Dan is an associate solicitor in the human rights department

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Gambling Inquests Human rights

Coroner concludes Luke Ashton died as a result of gambling disorder and a lack of meaningful intervention from Betfair

The inquest into the death of Luke Ashton has concluded that a gambling disorder caused his death by suicide. It is believed that this is the first time that this has ever been recorded in an inquest. Area Coroner Ivan Cartwright added that he will be making a Prevention of Future Deaths report, which will include his concerns about a lack of meaningful interaction or intervention in Luke’s gambling by the gambling operator Betfair, owned by Flutter.

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