Luke Ashton: Prevention of future deaths report

Other related deathsSuicide (from 2015)

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Date of report: 12/07/2023

Ref: 2023-0238

Deceased name: Luke Ashton

Coroner name: Ivan Cartwright

Coroner Area: Leicester City and South Leicestershire

Category: Suicide (from 2015) | Other related deaths

This report is being sent to: Betfair, Gambling Commission and Department for Culture, Media and Sport

[REDACTED], Chief Executive Officer (‘CEO’) of Flutter UK & Ireland, the parent company of ‘Betfair’ (through its legal representatives)
[REDACTED], Chief Executive Officer (‘CEO’) of the Gambling Commission
The Rt. Hon. Lucy Frazer KC, MP, Secretary of State for Culture, Media and Sport
I am Mr Ivan Cartwright, His Majesty’s Area Coroner for the coroner area of Leicester City and South Leicestershire.
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 06 May 2021 I commenced an investigation into the death of Luke Anthony Ashton aged 40. The investigation concluded at the end of the inquest on 29 June 2023.

The conclusion of the inquest was that:  
Narrative Conclusion:  
Luke Ashton died as a result of his own actions, intending those actions to cause his death. At the time of his death, Luke was suffering from a gambling disorder, which was longstanding, at least from 2019 and which contributed to his decision to take his own life. In the months prior to his death, the evidence showed that Luke had been assessed as a low-risk gambler by the operator with whom he was gambling, although Luke’s gambling activity, deposits made and losses suffered were most intensive in the 10 weeks prior to his death. The same operator did not intervene or interact with Luke, in any meaningful way, between 2019 and the date of Luke’s death, when more efforts to intervene or interact should have been made. Opportunities were missed which may possibly have changed the outcome for Luke.  

The cause of death was established as:  
I a ([REDACTED])  
I b Gambling Disorder
Luke Ashton was a 40-year-old man who was discovered deceased by attending police officers and paramedics at Carnegie House, Swinton, near Rotherham, South Yorkshire on 22 April 2021, [REDACTED]. His death was confirmed at the scene by one of the attending paramedics.
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is  my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
During the course of the inquest, evidence was heard about Mr. Ashton’s gambling activities, both prior to and, in greater detail, after July 2019. The evidence showed that Mr. Ashton had, at times, used a number of ways to protect himself from the potential of excessive losses from, and excessive deposits into, his online account, in order to gamble. Those methods included self-exclusion, temporary or permanent, from certain products and/or activities and placing limits on the value of his deposits and/or losses, during a specific, pre-determined period of time.
During the ‘relevant period’ examined closely during the investigation and inquest, between July 2019 and the date of Mr. Ashton’s death on 22 April 2021, although Mr. Ashton utilised a number of what are known as ‘player protection tools’, as outlined above, the operator he was gambling with during the relevant period, Betfair, did not take any measures, save for sending a number of e-mails to Mr. Ashton, to tell him about the existence of a number of protection tools that players could potentially access. During the relevant period, the evidence showed that Mr. Ashton was a problem gambler and, in the last 10-12 weeks of his life, his problem gambling became more acute, intrusive and, on balance, distressing to him.
1)    I remain concerned that the player protection tools, as mentioned above, were and are inadequate to protect a person such as Mr. Ashton, who was a problem gambler with a worsening problem, specifically that such tools do not amount to any or any meaningful interaction with the gambler, or any intervention into the practices of the gambler.
2)     I remain concerned that the algorithm devised and operated by Betfair, to assist its staff in, amongst other things, observing and monitoring the gambling patterns and practices of its customers, failed to flag up Mr. Ashton as a problem gambler, despite the increases in his time online (gambling) the value of his deposits and the size of his losses, in part because his gambling practices, even in the last 10-12 weeks of his life, were deemed not to be exceptional, when averaged among gambling customers, generally.
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.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 5th September 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
1.  [REDACTED] , wife of the Deceased (via her legal representatives, Leigh Day & Company).
2. Flutter Entertainment UK & Ireland (via its legal representatives).
I have also sent it to
1.       Gamble Aware (Charity, Registered in England No. 4384279)
who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may  send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.
His Majesty’s Area Coroner for Leicester City and South Leicestershire