Jack Ritchie inquest: Coroner finds “woeful” government failings

The inquest into the death of Jack Ritchie has concluded that the state failed in multiple respects and that this caused Jack’s death.

The coroner ruled that insufficient public health information, poor regulation and inadequate treatment all contributed to Jack’s death as the “warnings, information and treatment available to Jack were woefully inadequate.” He went on to conclude that there continue to be significant gaps remaining in these areas.

“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,” said Liz and Charles Ritchie after the inquest’s conclusion.

“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. 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.”

“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”

Liz and Charles Ritchie

The coroner has issued a report to prevent future deaths to central government because there continues to be an ongoing risk to the lives of others. You can read his prevention of future deaths report here.

The inquest heard that gambling led to Jack’s death. He took his life in 2017 after suffering from gambling disorder.

The coroner heard how it was well known across government departments and the Gambling Commission that gambling carried a high suicide risk, but that not enough was done to warn the public or to put effective treatment for gambling disorder in place. Instead, the coroner was told, the government delegated its responsibility to protect the public to charities that were funded on a voluntary and inconsistent basis by the gambling industry, the very industry that profits from the disorder its products create. The coroner heard that little has changed since Jack’s death in 2017.

The inquest heard evidence from the Department of Culture Media and Sport (DCMS), the Department for Health and Social Care (DHSC), the Gambling Commission, specialist clinicians, and the industry-funded charities GambleAware and GamCare. Witnesses spoke on the regulation of gambling and the information and support available to those suffering gambling disorder.

The inquest heard how current research, education and treatment programmes available in the UK are influenced by the gambling industry through voluntary funding arrangements, highlighting a need for such funding to be put on a statutory footing through a statutory levy on gambling operators.

Witnesses to the inquest including the Director General of the new Office for Health Improvement and Disparities at DHSC, Jonathan Marron, accepted that the UK is in the extraordinary position that frontline NHS staff, including GPs, have had little or no training to be able to recognise, diagnose or treat gambling disorder. The court heard that the industry-partner charities providing most treatment operate almost entirely outside the NHS with oversight by the Charity Commission not the Department of Health.

Jonathon Marron was overcome with emotion as he gave evidence, breaking into tears as he described how hard it was to hear Liz and Charles’ story while being a father himself. He said that a recent Public Health England review estimated around 409 people die in England each year as a result of gambling-related suicide and that the Department of Health was “looking to learn” from the inquest.

The inquest also revealed failures in regulation of dangerous gambling products, some with addiction and at-risk rates of up to 50 per cent. The court heard that the Gambling Commission,  – which is charged with regulating gambling products and industry practices – licenses products for consumption without prior safety testing, despite knowing that over 400 people a year take their lives due to gambling. Sarah Gardner, the Deputy Chief Executive of the Gambling Commission accepted that the progress that has been made in addressing gambling-related suicide has been “disappointing”.

“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.”

Will Prochaska, Strategy Director, Gambling with Lives

During the inquest, Zoe Osmond, the CEO of the charity GambleAware, and Anna Hemmings, the CEO of the charity GamCare, agreed that gambling disorder is created by gambling products, not by the personal attributes of those suffering. They agreed that their organisations would put the message “gambling kills” on their websites.

“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,” said Will Prochaska, Strategy Director at Gambling with Lives.

“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.”

The inquest heard expert evidence from Dr Matt Gaskell, who leads the NHS Northern Gambling Clinic, that the treatment which Jack received was insufficient and that this contributed to his death. Dr Gaskell spoke about the huge impact gambling has on the brain, causing major changes as addiction develops and that it can develop very quickly. He also said it was the whole public who are at risk, not a vulnerable few.

Jack began gambling under age at 17 when he and a group of school friends would use dinner money to play fixed-odds betting terminals (FOBTs) at a betting shop. Jack’s gambling was encouraged through easily accessible, dangerous forms of online products.

Jack died in Hanoi, Vietnam, on 22 November 2017. He had been living there for around three months teaching English. Before that, Jack lived in Sheffield, where he grew up.

The conclusion of Jack Ritchie’s inquest was covered in The Guardian, The Telegraph, The Times, BBC News, ITV, Sky News and others. You can read the coroner’s prevention of future deaths report here.