“Arthur was a ray of sunshine,” his family said following his inquest. “He was kind, thoughtful, intelligent and deeply loved.”

Arthur Soames grew up in Fulham, west London. He was a talented sportsman who represented his school in tennis and squash. He also loved skateboarding and music, played both the guitar and drums, enjoyed spending time outdoors, joined the Army Cadets, took part in charity hikes and coached tennis to local children.

Shortly after turning 18, Arthur opened an online gambling account and began betting on sport. Over the following months, his gambling escalated rapidly. The inquest heard that, after receiving inducements, he moved on to online casino games and developed Gambling Disorder within a relatively short period of time.

Arthur’s gambling had a profound effect on his mental health. The inquest heard that gambling was discussed during therapy sessions and formed part of the difficulties he was experiencing. However, the coroner concluded that opportunities to properly assess and respond to the risks associated with Arthur’s gambling were missed. The inquest found that failings in the mental health care he received contributed to his death.

The inquest also examined Arthur’s interactions with a gambling operator. Evidence showed patterns of gambling behaviour that experts said should have prompted stronger intervention. Despite this, the company sent only a single automated safer gambling email and took no meaningful steps to reduce the risks associated with his gambling.

Arthur died by suicide in May 2022 at the age of 19. Following the inquest into his death, Assistant Coroner Ian Arrow concluded that Gambling Disorder contributed to his death, alongside anxiety and depression. He also found that failings in Arthur’s mental health care contributed to the outcome and indicated that a Prevention of Future Deaths report would be issued.

Since Arthur’s death, his family have spoken publicly about the need for Gambling Disorder to be recognised and treated as a serious health condition. They have also called for stronger safeguards to ensure gambling operators respond appropriately when clear signs of harm emerge, so that other families are less likely to experience the same loss.