Recurring concern

Unreliable identification and support for gambling-related harm

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First reported 7 Mar 2022•Latest report 14 Jan 2026

Definition

What this concern includes

Includes controls specifically dedicated to identifying, preventing or responding to gambling-related harm, including asking patients about gambling habits and providing clear, supportive information to people affected by gambling addiction.

Not included

  • Excludes generic mental-health assessment, communication or information-provision failures that are not specifically tied to gambling-related harm.
  • Excludes general addiction services or substance-use concerns unless gambling or gambling addiction is the identified safety issue.
  • Excludes neutral descriptions of gambling, gambling behaviour or gambling services without an unsafe identification or support deficiency.
  • Excludes downstream suicide, shame or hopelessness outcomes when no dedicated gambling-related identification or support failure is asserted.
Reports
4

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2022–2026

First to latest report issue date

Stated actions
6

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Digital, Culture, Media and Sport3
Department for Education2
Department of Health and Social Care2
Gambling Commission2
Flutter UK & Ireland1
Royal College of General Practitioners1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East Sussex

    AI-generated summary

    Oliver Anderson Long · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Oliver Anderson Long, known as Ollie, was found dead on 23 February 2024 after travelling to East Sussex and leaving notes indicating an intention to take his own life from cliffs. He had a history including gambling disorder and, despite self-exclusion from licensed online gambling, was able to access unlicensed gambling sites. The principal concern was that unlicensed sites are outside the protections of regulated gambling and that there is inadequate public health information and warning about their risks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of gambling-harm protection features on unlicensed sites

    Wider context from the report

    “Consumers are unlikely to check that a site is licenced prior to accessing it, particularly if the advert for the site is in a trusted space, such as on social media. The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains, and they may not be aware that these features are unlikely to be present on the site they are using. ”

    Source location

    Oliver Anderson Long · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen protections for people at risk through new safer-gambling requirements.

    Verbatim wording from the response

    “23. The Government remains committed to tackling gambling-related harms. Working with the Gambling Commission, DCMS is committed to strengthening protections for those at risk through a range of new safer gambling requirements. DCMS and the other CGDs will continue to review the best available evidence to inform our decisions on how best to fulfil our commitment to tackle gambling-related harm.”

    Source location

    Response from Department of Culture Media and Sport
    Page 4 · response
    Published 21 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    DCMS, as lead department for gambling policy and regulation, will lead and submit the cross-agency response on behalf of the named organisations.

    Verbatim wording from the response

    “In relation to the matters of concern set out in your report, DCMS, as the lead government department responsible for gambling policy and regulation, is leading the development of a single cross-agency response, working collaboratively with relevant policy officials across the named organisations. DHSC fully supports this approach and is actively contributing to the response, particularly in respect of public health considerations.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for the matters raised lies outside the Department’s remit, so it will not undertake responsive safety work.

    Verbatim wording from the response

    “Officials within the Department for Education have undertaken a review of the report and fully recognise the importance of the issues you have raised. Following this consideration, we have concluded that responsibility for these matters lies outside the remit of this Department. The organisations identified within the report may be best placed to provide you with a full and comprehensive response, and we trust they will be able to address your concerns appropriately.”

    Source location

    Response from Department for Education
    Page 1 · response
    Published 21 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The organisations identified in the report may be best placed to provide a comprehensive response and address the concerns.

    Verbatim wording from the response

    “Officials within the Department for Education have undertaken a review of the report and fully recognise the importance of the issues you have raised. Following this consideration, we have concluded that responsibility for these matters lies outside the remit of this Department. The organisations identified within the report may be best placed to provide you with a full and comprehensive response, and we trust they will be able to address your concerns appropriately.”

    Source location

    Response from Department for Education
    Page 1 · response
    Published 21 January 2026

    Open published response
  2. Inner South London

    AI-generated summary

    Lee Derek Jamie ADAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lee Derek Jamie Adams died after taking an excessive number of propranolol tablets on 24 July 2020, following extensive online gambling and in the context of depressive illness. The substantive concerns included the rapid absorption and high toxicity of propranolol, the lack of a specific antidote, and the need for GPs to consider patients’ gambling habits and the risks of excess propranolol ingestion.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of GPs to ask individuals about gambling habits

    Wider context from the report

    “(5) GPs should be reminded to ask individuals about their gambling habits in the same way that they ask about smoking and alcohol. ”

    Source location

    Lee Derek Jamie ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide a Gambling Harms Hub accreditation pathway with e-learning, webinars, practice leads and staff-training materials for addressing gambling harms.

    Verbatim wording from the response

    “In addition to the GP curriculum, the RCGP Gambling Harms Hub is available for our members which encourages our members to complete the eLearning course and webinar to be eligible to become a Gambling Harms accredited practice, with an established practice lead who is sent a staff training research pack that is intended for sharing with the practice team. Gambling Harms Accreditation:”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 26 March 2026

    Open published response
  3. Leicester City and South Leicestershire

    AI-generated summary

    Luke Anthony Ashton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Luke Anthony Ashton, a 40-year-old man, was discovered deceased at Carnegie House, Swinton, on 22 April 2021, and his death was confirmed at the scene. The inquest found that he had a longstanding gambling disorder and that his gambling activity, deposits and losses were most intensive in the 10 weeks before his death. Concerns included the adequacy of player protection tools, Betfair’s failure to identify his worsening gambling through its monitoring algorithm, and the lack of meaningful intervention or interaction.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Reliance on industry regulatory standards rather than current good or best practice for gambling-customer protection

    Wider context from the report

    “3) I remain concerned that, as was apparent through the evidence of a senior employee witness during the course of the inquest, the operator Betfair appears to judge the extent of its responsibilities to gambling customers solely with regard to industry (regulatory) standards, rather than current good or best practice in order to prevent further harming problem gamblers, or those who, as a result of their changing practices and patterns are likely to become problem gamblers. ”

    Source location

    Luke Anthony Ashton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue improving and refining licensing requirements, remote technical standards and associated guidance using regulatory evidence and research.

    Verbatim wording from the response

    “71. The Commission can, however, confirm that the framework of gambling regulation is designed to be outcomes focussed. While there are prescriptive requirements within the LCCP, it isn’t possible to regulate for every individual circumstance. That is why operators are expected to conduct their gambling operations in a way that does not put the licensing objectives at risk and the Commission will hold an operator’s senior operational staff and directors accountable for regulatory compliance and the protection of the licensing objectives (see paragraph 3.12 and 4.1 of the Commission’s Statement of Principles). Further, the Commission expects licence holders to, amongst other things ‘…comply with both the letter and spirit of their licence and associated Commission regulations…’”

    Source location

    Response from Gambling Commission
    Page 22 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish information from regulatory casework to share lessons learned and inform good practice across the gambling industry.

    Verbatim wording from the response

    “73. The Commission hopes that the Coroner can therefore be assured that, as the regulator of gambling in the Great Britain, the Commission expects operators to comply with both the letter and the spirit of their licences and the regulations and requirements surrounding them. The Commission continues to improve and refine the regulatory framework of requirements, including LCCP requirements and remote technical standards. We also review and update associated guidance to support the sharing of good practice, as well as publishing information following regulatory casework to share lessons learned and further inform good practice across the industry.”

    Source location

    Response from Gambling Commission
    Page 23 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue strengthening and improving Player Protection Tools and actively encourage customers to use them.

    Verbatim wording from the response

    “20. The use of Player Protection Tools is actively encouraged across Flutter’s entire customer base. The tools are widely promoted in our marketing campaigns (broadcast, display and digital) and on our social media channels. We strongly believe the use of Player Protection Tools is a positive behavioural indicator and that their use can help customers enhance awareness of their gambling activity and stay in control of their gambling. In fact, Flutter has a company-wide goal, linked to employee bonuses, to significantly increase the share of customers using Player Protection Tools. As of 31 July 2023, over 37% of Betfair’s customer base were using a Player Protection Tool, an increase from 21% of the customer base as of 31 July 2021.”

    Source location

    Response from Flutter
    Page 4 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a dedicated Customer Safety Tribe of over 300 colleagues to advance safer-gambling controls.

    Verbatim wording from the response

    “50. The safety of our customers is of utmost importance to us. It is a core part of the mission, strategy and values of Flutter, which are communicated to all employees on joining, and discussed and re-committed to on a regular basis in internal communications by our CEO and senior leadership teams. Our safer gambling strategy is something we have consciously challenged all our colleagues to live and breathe on a day to day basis, and is constantly driven forward by over 300 colleagues in our dedicated Customer Safety Tribe. We are committed to operating to the highest standards in the industry and to continuing to improve our safer gambling controls to protect our customers from gambling-related harm.”

    Source location

    Response from Flutter
    Page 10 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No regulatory action was considered appropriate regarding the matters identified in the review of the individual case.

    Verbatim wording from the response

    “55. The date of activity on Mr Ashton’s account was prior to the completion of the special measures process (during which Betfair implemented controls to remedy the concerns that had been identified by the Commission in December 2020) and our follow-up assessment in May 2021 which concluded that Betfair had made sufficient progress on their implementation of updated safer gambling controls. Having considered the information relating to Mr Ashton’s gambling activities and the actions of Betfair, in November 2021 the Commission decided that it would not be appropriate to take regulatory action in respect of the matters identified during the review of Mr Ashton’s case.”

    Source location

    Response from Gambling Commission
    Page 18 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Betfair is primarily responsible for taking forward good or best practice, limiting the regulator’s ability to respond to this concern.

    Verbatim wording from the response

    “70. While the Commission is committing to responding as fully as possible to the Coroner’s concerns, it appears that this concern relates primarily to Betfair and how Betfair itself takes forward good or best practice. As such, the Commission’s ability to respond is necessarily limited.”

    Source location

    Response from Gambling Commission
    Page 22 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There is no specific minimum or objectively measurable best-practice standard for gambling operators beyond principle- and outcome-based regulatory requirements.

    Verbatim wording from the response

    “43. As a licensed operator, we are required to meet strict regulatory standards pursuant to our licence from the Gambling Commission. These regulatory standards, and in particular the social responsibility obligations contained in the Gambling Commission’s Licence Conditions and Codes of Practice (“LCCPs”), are principle-based and outcome-based expectations for the protection of individuals. Flutter Entertainment plc holds many gambling licences across the world and engages with over 40 regulators globally. Our consistent experience is that British gambling regulation is one of the most developed frameworks globally, with the Gambling Commission one of the global industry’s most widely-respected regulators.”

    Source location

    Response from Flutter
    Page 8 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The regulatory framework is outcomes-based and requires operators to pursue licensing objectives, not merely comply with minimum standards.

    Verbatim wording from the response

    “16. This concern is addressed to Betfair specifically, however in seeking to provide a full response I recognise the concern that other operators may similarly seek only to meet the minimum standards of regulation and legislation.”

    Source location

    Response from Department for Culture, Media and Sport
    Page 4 · response
    Published 18 July 2023

    Open published response
  4. South Yorkshire (Western)

    AI-generated summary

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack William Ramsey Ritchie died on 22 November 2017 from multiple injuries after an incident in Hanoi, Vietnam, in which the evidence indicated he intended to take his own life. The report raised concerns about gambling regulation, warnings, information, treatment, professional training, the stigma associated with gambling addiction, and limited education for young people about gambling harms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuing gaps in gambling-related information

    Wider context from the report

    “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of medical professional training in diagnosing and treating gambling addiction

    Wider context from the report

    “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of understanding that gambling addiction is not the individual's fault

    Wider context from the report

    “- Jack didn’t understand that being addicted to gambling wasn’t his fault. That lack of understanding lead to feelings of shame and hopelessness which in turn, contributed to him feeling suicidal ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuing gaps in gambling warnings

    Wider context from the report

    “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of gambling education for school children

    Wider context from the report

    “- The evidence was that young people were the most at risk from the harms of gambling yet there was and still appears to be, very little education for school children on the subject. ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient gambling warnings to prevent gambling

    Wider context from the report

    “- The warnings Jack received were insufficient to prevent him gambling ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuing gaps in gambling addiction treatment

    Wider context from the report

    “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient treatment for gambling addiction

    Wider context from the report

    “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction ”

    Source location

    JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026