Advising with empathy and experience

Coroner condemns 'woefully inadequate' care for gambling addict


A coroner has described the information and treatment available for a 24-year-old problem gambler who took his own life in Vietnam as “woefully inadequate.”

Yorkshire South West acting coroner, David Urpeth, delivered a narrative verdict at the inquest into the death of gambling addict, Jack Ritchie, who was teaching English in Hanoi.

Jack Ritchie’s parents, Charles and Liz Ritchie, had fought for an inquest that examined state regulation of the gambling industry as well as their son’s death.

The coroner did not rule that any arm of the state had directly breached any duty to protect Ritchie’s life but said “warnings, information and treatment” for problem gamblers at the time of Ritchie’s death were “woefully inadequate and failed to meet Jack’s needs.”

He added that the situation had improved but “significantly more” needed to be done.

David Urpeth said he would write to government departments and gambling agencies with warnings about how future deaths could be prevented. He also highlighted the need for more training for GPs about gambling disorders.

The inquest heard evidence that as many as 400 suicides a year in England could be linked directly to gambling.

The Ritchie family argued that gambling killed their son. They said that: “It was the long-term root and the short-term trigger of Jack’s death.”

David Urpeth agreed saying it was “abundantly clear” that gambling contributed to Ritchie’s death.

The coroner praised Ritchie’s parents and said they had done all they could to help their son.

It is believed to be the first time article 2 of the Human Rights Act has been engaged in a case of suicide after gambling which meant that its scope included examining whether any arm of the state breached its duty to protect Ritchie’s right to life. Engaging article 2 had been opposed by lawyers representing the government.

Jack Ritchie’s gambling problem started when he was a sixth-former at school, putting small stakes at a betting shop on controversial fixed-odds betting terminals (FOBTs).

This habit escalated over time, with Ritchie gambling away money left to him by his grandmother, his student loan while studying history at Hull University and, his bank overdraft while he was in Vietnam.

Jack’s parents set up a charity, Gambling With Lives, to support affected families and raise awareness of the dangers of gambling. The campaign says “very normal, bright, popular and happy young folk” are killing themselves and “gambling was their only problem.”

Ritchie was described by his father as “big in physique and in personality … big in heart and in spirit.”

Afterwards, Liz Ritchie told the Guardian it was “an extraordinary, seismic ruling” and described the future death notices as “really clear instructions to government to do things better.”

She added: “The coroner found multiple state failings in regard to gambling in terms of regulation, treatment and information.” Those failings, she said, “killed Jack, they caused his death. So it was a huge ruling.”

Charles Ritchie said the prevention of future death orders issued by the coroner were beyond what they could have hoped for.  He said: “Jack died four-and-a-half years ago so it has been a long, long journey and to get that as a set of rulings is extraordinary.”

The couple said: “For us, this inquest has been about justice for Jack. Jack died believing he was the problem and he was harming his family and us. This is not true and the coroner found explicitly that it was not Jack’s fault.

“Jack was abused by parasites that inflict life-threatening illness for profit and then blame the victims. Jack’s inquest revealed that the link between gambling and suicide has been known for years but it’s taken the deaths of thousands to start to make proper change.”

Witnesses at the inquest included a senior civil servant at the Department of Health and Social Care, director general for the Office for Health Improvement and Disparities, Jonathan Marron, who said: “I don’t think there’s any dispute that there’s an association between gambling and suicide.”

He acknowledged the trauma Jack’s parents had been through and said: “It’s clear that the work you have done has had a significant role in changing the focus of this issue.”