David Clifton: Licensing Expert – The story behind a tragic story

David Clifton

As previously reported by SBC News, a two-week-long inquest into the death of Jack Ritchie, a 24-year old English teacher with a long-standing gambling disorder, ended on 4 March 2022 with the coroner concluding that ‘warnings, information and treatment’ for problem gamblers had been ‘woefully inadequate and failed to meet Jack’s needs’.

Paul Greaney QC, who was instructed to represent the family of Jack Ritchie at the inquest, has reported that, for the first time, Article 2 of the European Convention on Human Rights (‘ECHR’), i.e the ‘right to life’, had been engaged in a case relating to suicide after gambling. He added::

“The coroner … identified multiple state failings. He concluded that Jack’s unnecessary death was explicitly not Jack’s fault. Gambling Disorder is not a failure of individual responsibility. It is an Addictions Disorder”.

Junior Counsel for the Ritchie family was Jesse Nicholls of Matrix Chambers. More detail is provided on the Matrix Chambers website, which states as follows:

“Jack died in Hanoi, Vietnam, on 22 November 2017. On the day of his death, Jack had been gambling all day and had emailed his parents and posted on Facebook to indicate that he planned to end his life. He began gambling aged 17 and continued through easily accessible online betting over the following years.

The inquest investigated the role that gambling played in Jack’s death and whether the State could have prevented his death, and heard evidence from a number of senior witnesses about the information and treatment available to Jack, as well as the State’s regulation of gambling. The inquest is believed to be the first in England and Wales to examine the State’s role in a gambling-related death and was held as an Article 2 Middleton inquest following an earlier successful argument made by Jack’s family.

HM Senior Coroner, David Urpeth, concluded that the regulation, information and treatment for gambling problems at the time of Jack’s death were ‘woefully inadequate’ and probably contributed to Jack’s death. The treatment available for gambling problems was insufficient, there was a lack of training for medical professionals and a lack of information available to the public. He concluded that Jack did not understand that gambling was not his fault and this led to feelings of shame and helplessness. The Coroner also found that 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, information and education. As a result of these outstanding issues, which the coroner was concerned presented a risk of further deaths, the coroner will make 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.”

A Gambling Commission spokesman has been quoted in the media as saying:

“Jack’s death was a tragedy and we have met and spoken with Jack’s parents on several occasions to understand and agree how we can learn from their experience to inform the way we work. These conversations, along with those of others who have experienced harm, strengthens our commitment to protect consumers and make Britain’s gambling market fairer and safer.”

This very sad news merits further explanation of the story behind the story.

Following Jack Ritchie’s tragic suicide, his parents (Charles and Liz Ritchie) became co-founders of the charity ‘Gambling with Lives‘.

That charity gave written evidence to the House of Lords Select Committee on the Social and Economic Impact of the Gambling Industry. Mr and Mrs Ritchie also gave oral evidence to the Committee, during which they answered questions (posed by Lord Trevethin and Oaksey) regarding Article 2 of the ECHR.

The transcript of their evidence records the following exchanges:

Liz Ritchie: There is no doubt in my or Charles’s mind that my son’s right to life was not protected by the state. Deregulated gambling did not put in safeguards for him and his generation. He is one of a generation. Jack and possibly thousands have died since 2007 because of this failure, and the state has done nothing to find out whether that is the case. DCMS was arguing for the shortest possible kind of inquest—15 minutes—at Jack’s pre-inquest review. In other words, it was saying, “We don’t want to know why he died. We don’t want to know if gambling was implicated”.

Lord Trevethin and Oaksey: Did DCMS have counsel at the preliminary hearing that made that representation?

Liz Ritchie: Yes, as did the Gambling Commission. Actually, it was saying different things, to be honest. DCMS was saying it gambling was not dangerous and the Gambling Commission was saying, “It is dangerous, but it is not our job to warn the public”.

Charles Ritchie: At one level, we were shocked. It was almost, in Jack’s case, “You don’t need an inquest to say that he died because of gambling”. 

Gambling with Lives‘ extremely detailed supplementary written evidence to the House of Lords Select Committee conceded that “it is widely acknowledged that the causes of any individual suicide can be complex, both in terms of the long-term history of the individual and any specific events which might trigger their death”. Determining the cause of suicides is indeed extremely complex, as evidenced by the following comment by Rory O’Connor (Professor of Health and Psychology at the University of Glasgow) in his book ‘When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It’, published last year:

“Contrary to some media reports, suicide is not caused by a single factor. Instead, it is the end product of a complex set of biological, psychological, clinical, social and cultural determinants that come together in a perfect storm. For most, suicide is not about wanting to end one’s life but about wanting unbearable mental pain to end.”

However, Gambling with Lives’ supplementary written evidence to the Select Committee went on to say: “there is a substantial research base which indicates that gambling itself can be a prime cause of suicidal behaviour”.

I believe that the coroner’s subsequent conclusion that ‘woefully inadequate’ regulation, information and treatment for gambling problems back in 2017 ‘probably contributed’ to Jack Ritchie’s death was as far as he could have gone in terms of explaining the cause of his suicide by reason of a restriction imposed on coroners by section 5(3) of the Coroners and Justice Act 2009.

The statutory restriction in relation to matters on which a coroner may express an opinion was explained in the following manner at paragraphs 303-307 of the House of Lords Select Committee’s Report entitled ‘Gambling Harm – Time for Action’, published on 2 July 2020:

“It is not, and never has been, part of the duties of coroners to record the reason for a death; they have always been limited to discovering “who, when, where and how”, but not “why” a person died; indeed there is a statutory prohibition on such a finding. There is a good reason for this: “why” often involves deciding that a criminal offence has been committed, often with an indication of the likely perpetrator, and this would impact on the criminal process and might prejudice a fair trial. But the result is that a finding that a death was the result of suicide will not say that the suicide was caused in whole or in part by gambling, even if the coroner believes that this was the case. Coroners’ offices therefore have no record of gambling-related suicides.”

The Select Committee went on to recommend that the Notification of Deaths Regulations 2019 (made under the Coroners and Justice Act 2009) should be amended to include, in the list of information that doctors are required to provide to coroners, a requirement – when a doctor suspects that a death by self-harm was gambling-related – to inform the coroner of this. It also recommended that:

“Coroners’ offices should keep a record of such information and forward it at intervals to the Ministry of Justice, which must collate it and keep a list of the numbers of deaths by self-harm which doctors suspect were gambling-related. The numbers of such deaths, but not details of individual deaths, should be publicly available”.

Addressing these recommendations, the Government’s formal response to the Select Committee’s report stated:

“The government recognises that quality information on the circumstances leading to self-harm and suicide, including gambling issues, can support better interventions. However, in order to be useful, this information must be consistent, which we do not consider achievable through doctors’ notifications to coroners. This is because, as the Committee points out, doctors may apply differing criteria or not identify gambling to be a factor. Further, not all deaths subject to a coroner’s investigation, including deaths by self-harm or suicide, will have been notified by a medical practitioner. Therefore, the information that could be collected through doctors’ notifications would be partial at best.

In addition, this would require medical practitioners to provide coroners with information that, in many cases, would not be relevant to their investigation or subject to the coroner’s consideration. As the Committee observes, it is generally beyond the coroner’s jurisdiction to determine why someone died, with the aim of an inquest being to determine who died, and how, when and where they died. This is for a number of reasons, including the fact that a coroner’s investigation is a fact-finding exercise and coroners are forbidden by statute to apportion civil or criminal liability. We note that the circumstances in which the doctor’s duty to notify arises, listed in regulations 3(1)(a) and 3(1)(b) of the Notification of Deaths Regulations 2019, all relate to the question of ‘how’ someone died and not ‘why’ they died.”

I believe it inevitable that the coroner’s conclusions in the inquest into Jack Ritchie’s death will feature in the forthcoming debates on gambling law reform following publication of the Government’s Gambling Act Review White Paper, now seemingly delayed until May this year. That is not least because one of the three principal objectives of that Review is to “ensure there is an appropriate balance between consumer freedoms and choice on the one hand, and prevention of harm to vulnerable groups and wider communities on the other”. In the meantime, it will of course remain the case that all UK licensed gambling operators are obliged to promote the third licensing objective under the Gambling Act 2005, namely to protect children and other vulnerable persons from being harmed or exploited by gambling.

It will hopefully be borne in mind in those debates that the coroner’s comments in relation to insufficiency of publicly available information, treatment available for gambling problems and training for medical professionals reflected the position as he perceived it to be in 2017. There have since then been positive developments in each of those respects, despite the coroner’s reported concern about there still remaining “significant gaps in treatment, information and education”.

For the avoidance of doubt, I don’t for one moment seek to argue with the coroner’s opinion. There is clearly room for further improvement in those respects, although I suspect many within the industry may regard as a backward step the decision by the NHS to break its funding ties with GambleAware with effect from 1 April.

All that I have said above regarding the coroner’s findings makes even more noteworthy the circumstances behind the Gambling Commission’s recent announcement of the third-highest financial penalty ever imposed on a UK licensed gambling operator, i.e. the £9.4million fine incurred by 888 UK Limited for AML and social responsibility failings, prompting the regulator’s CEO to warn: “all should be clear that if there is a repeat of the failures at 888 then we have to seriously consider the suitability of the operator to uphold the licensing objectives and keep gambling safe and crime-free”.

It would be too obvious and trite to seek to excuse as ‘historic’ the failings in the 888 case, or indeed those behind the recent BetVictor £2million regulatory settlement. Lessons can, and surely must, be learned from all regulatory enforcement action taken by the Commission, regardless of when the failings occurred. Such a lesson certainly exists in the case of BetVictor because, as the public statement makes clear, in addition to AML and social responsibility failings, the Commission found that the contractual terms on which the operator had offered its gambling facilities were unfair. This followed very soon after publication by the Commission (on 16 February) of updated guidance on fair and transparent terms and practices – essential reading material for all UK licensed gambling operators, not least because it contains four wholly new sections.

To be honest, I had originally intended this article to focus on the Gambling Commission’s latest participation and prevalence data which, for the first time in years, has shown a more positive change in respondents’ perceptions of gambling, including (a) a significant increase in the proportion of past 12 month gamblers who agree that gambling is conducted fairly and can be trusted and (b) significantly fewer respondents who agree that ‘gambling is dangerous for family life’. I trust you will understand why, in view of the considerably more sobering topic on which I have instead focused, I have relegated this news to a passing comment.

More information about that and other topical gambling regulatory issues can be found in the ‘Articles/News’ section of the Clifton Davies website.


David Clifton Director Clifton Davies


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