Dear Mr Cartwright,

Response to Regulation 28 report following inquest into the death of Luke Ashton

1. I write in response to the Regulation 28 Report to Prevent Future Deaths (the “Report”) dated 12 July 2023, made following the inquest into the death of Luke Ashton.

2. In providing this response to the Report, I wish to express my deepest sympathies to Mr Ashton’s family and friends for their loss. The Department for Culture, Media and Sport (“DCMS”) and wider government are committed to protecting people from gambling related harms and preventing future tragedies under similar circumstances. We have carefully considered the concerns you highlight, and will continue to take action to make gambling safer and increase protections for those at risk of harm.

3. The Report arises from the Inquest into Mr Ashton's death which finished on 29 June
2023. You concluded that the evidence showed that gambling disorder had contributed to Mr Ashton’s decision to take his own life, and you established gambling disorder as a cause of death. The particular matters of concern identified in the Report were that:

i. That the player protection tools were and are inadequate to protect a person such as Mr Ashton, 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.
ii. 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.
iii. That 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.

Background

4. Ensuring that gambling happens safely is a top departmental priority. From December 2020 to April 2023 the government undertook a comprehensive Review of the Gambling Act 2005. The Review launched with a call for evidence which ran from December 2020 to March 2021 and received 16,000 submissions. Ministers and officials have supplemented this with hundreds of meetings with a wide range of stakeholders, including those bereaved by gambling related suicide. We are particularly grateful to those like Mr Ashton’s widow who have shared their personal experience with DCMS and highlighted priorities for change. We have assessed the best available evidence and in April we published a white paper outlining a comprehensive package of new protections to build on existing controls and help safeguard customers.

5. A number of the proposals in the white paper relate to the protection of online gamblers, and these are being introduced in addition to the specific changes outlined below in relation to your concerns. For example, we are creating new obligations on operators to conduct checks to understand if a customer’s gambling is likely to be harmful in the context of their financial circumstances, seeking to mandate participation in a cross- operator harm prevention system based on data sharing, bringing in new rules to make online games safer by design, and introducing a maximum stake limit for online slots games. We will also continue to tighten rules on advertising and marketing, tackling aggressive practices like using bonuses in ways which exacerbate harms, and working with health and behavioural science experts to develop independent messaging that raises awareness of the risks of gambling. We are working at pace to deliver these and other white paper proposals as soon as possible.

Concern I: The player protection tools were and are inadequate to protect consumers and do not amount to any meaningful operator interaction or intervention

4. All licensed online operators are required to provide customers with a range of tools to help them gamble safely, such as gambling activity statements, ‘time out’ functionality, and facilities to set limits on spend. Operators must also provide facilities to allow gamblers to self-exclude, and since March 2020 all remote operators have been required to integrate with GAMSTOP, the national self exclusion scheme. While the use of these tools by customers is voluntary and operators are afforded a degree of discretion around how they are designed, there are requirements attached to certain tools, and encouraging or mandating customers to use them is part of the range of interventions operators are expected to consider for those showing indicators of harm.

5. The Gambling Act Review gave extensive consideration to these tools, and we received evidence that many customers find them a useful way of controlling their gambling spend.

6. However, the white paper recognised opportunities to improve both the uptake of the voluntary tools, and their efficacy in preventing harm. For example, building on evidence from the Behavioural Insights Team the review found that the design of many currently available deposit limits (as the most widely used safer gambling tool), is sub-optimal and likely to encourage the setting of high monetary limits which may not prevent harm as intended.

7. As outlined in the white paper, the Gambling Commission will consult on implementing improvements to customer-led tools such as making them mandatory or opt-out rather than opt-in, or pre-populating tools like deposit limits with a default spending limit. The Commission is also continuing a programme of work to support the efficacy of multi- operator self exclusion tools.

8. As an additional protection, we will also continue work with the gambling and financial services sectors to make customer-controlled gambling transaction blocks as robust as possible, for instance by expanding them to cover non-card payment methods. Finally, the Gambling Commission’s new customer interaction requirements put a specific obligation on operators to consider a customer’s use of gambling management tools when assessing for signs of risk (outlined below). I am hopeful that these changes can and will address your concerns.

9. However, while these tools are helpful for many online gamblers, we acknowledge that they alone are not enough to fully mitigate the risks and may not be effective for those in the grips of an addiction. They are therefore only part of the player protection package which we, alongside the Gambling Commission, have taken significant steps to strengthen over recent years, and will continue to do so following the gambling white paper.

Concern II: Betfair’s harm detection algorithm failed to flag Mr Ashton as at risk despite displaying indicators of harmful gambling

10. All remote gambling operators must monitor player behaviour and use the wealth of data they have available to identify those who may be at risk and take action to protect them, in line with the Gambling Commission’s licence conditions and customer interaction guidance. Where needed, the actions taken must include encouraging or requiring a player to set limits, actively signposting to support services, suspending marketing in cases where there are strong indicators of harm, and unilaterally suspending or closing accounts.

11. Despite this, we are aware that operators’ approaches vary and there have been too many cases of interventions coming too late, or in some cases not at all. While the Commission has taken strong enforcement action where operators failed to meet the customer interaction requirements, it has also taken steps to substantially strengthen the rules themselves with a view to preventing future harm.

12. These new requirements which came into force in September 2022 and February 2023 clarify operator responsibilities around customer interaction and mandate consistency in harm detection algorithms across the sector. In particular, Social Responsibility Code
3.4.3 now specifies seven relevant categories of “indicators of harm” which all operators must monitor from the moment an account is opened. The core indicators that operators must use are:

a. customer spend
b. patterns of spend
c. time spent gambling
d. gambling behaviour indicators 
e. customer-led contact 
f. use of gambling management tools
g. account indicators.

13. In addition, the code sets out how operators must tailor the action they take based on these behavioural indicators and the level of risk identified. This includes requirements around responding to concerns in a timely manner (including with automated processes where appropriate), preventing direct marketing to or the use of bonus offers by those showing strong indicators of harm, and effective evaluation of any customer interactions. To support operators in fulfilling these requirements, new guidance was published in August 2023 and will come into effect this autumn. The guidance includes specific expectations for operators to identify and intervene with customers who may be at risk of suicide, including where necessary through referrals to emergency services.

14. We understand that since Mr Ashton’s death, Betfair has made significant changes to its controls, including mandatory deposit limits for customers who return after a period of self-exclusion.

15. The new rules above have strengthened requirements on gambling businesses to monitor, identify and protect customers at risk of harm. However, a number of measures outlined in the white paper are intended to reduce the reliance on inherently reactive harm detection algorithms by placing a greater focus on preventing harms, such as unaffordable losses, in the first place. At the time of writing, the government is consulting on proposals for a maximum stake limit on online slots games. The Gambling Commission is also consulting on a number of proposals including to make online games safer and to introduce a system of financial risk checks with clear thresholds for operator action.

Concern III: Betfair is only adhering to minimum regulatory standards and is not striving to improve outcomes for consumers via good or best practices

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.

17. The regulatory framework is designed to be outcomes based as it is impossible for the regulatory and legislative requirements to foresee every circumstance which might arise in the course of a licensee’s business. However, I am clear that all operators must strive to deliver the high level licensing objectives (protecting children and vulnerable people, keeping gambling fair and open, and ensuring it is crime free) as well as the specific requirements in individual areas.

18. Both DCMS and the Gambling Commission have sought to encourage the adoption of best-practice where socially responsible operators have taken ownership of these objectives. We have welcomed voluntary initiatives which are evidence based and likely to minimise the risk of gambling related harm, both within individual operators and those coordinated by trade bodies.

19. More broadly we have encouraged a ‘race to the top’ through issuing industry challenges and, where best practice does emerge, mandating all operators to meet that standard. This removes the potential commercial disadvantage for early movers, and incentivises continuous improvement across all licensees. The mandated integration of all remote operators with GAMSTOP or the inclusion of the Industry Group for Responsible Gambling (IGRG) responsible advertising code in Ordinary Code provisions are examples of where this approach has successfully raised standards across the sector.

Conclusion

20. The government remains committed to tackling gambling-related harms. We are working with the Gambling Commission, the industry, and others to progress and implement the white paper proposals as quickly as possible, with a view to the main measures being in force by summer 2024. We will continue to adopt a proactive approach to bring about necessary improvements in the areas where evidence suggests further action may be required.

21. I hope that the matters set out above address, in sufficient detail, the concerns raised in the Report. If, however, further information or clarification would be of assistance DCMS will of course endeavour to provide this, as required.

Dear Sir Inquest touching on the death of Luke Ashton: Response to Regulation 28 Report

1. We refer to the Regulation 28 Report to Prevent Future Deaths dated 12 July 2023 (the “Report”), made following the inquest into the death of Luke Ashton.

2. This response is sent on behalf of Flutter UK & Ireland (“Flutter”), a division of Flutter Entertainment plc. Betfair is one of the core brands of Flutter. Further information on Flutter is set out in the Appendix.

3. Flutter takes customer safety extremely seriously, and we welcome the opportunity to respond to the Report. The purpose of this letter is to set out the steps taken, or intended to be taken, by Flutter in respect of the three matters of concern detailed in the Report.

Introduction

4. Before responding to the specifics of the concerns set out in the Report, we would like to give an overview of Flutter’s approach to customer safety. We would also like to once more express our sincere condolences to Luke Ashton’s wife and family for their loss.

5. Flutter holds itself to the highest standards in our industry and aims to lead in the area of safer gambling and customer protection. While the vast majority of people use our products without problem, we are aware that for some, gambling has the potential to be harmful. Therefore, safer gambling is a priority for all brands at Flutter, and we are constantly reviewing and updating our systems of checks and controls.

6. Flutter’s safer gambling strategy seeks to make every moment safe for our customers. This strategy sits at the very heart of Flutter’s business and within each of Flutter’s brands. The strategy was refreshed in 2022 after gathering insights from industry experts, customers and colleagues. We identified priority issues to focus on and assessed areas where we aim to go further. The five core pillars of Flutter’s safer gambling strategy are:

a. Discover - Proactively advance the industry’s understanding of gambling harm.
b. Educate - Improve all customers’ and colleagues’ understanding of gambling harm.
c. Empower - Give every customer the tools and understanding to use our products safely.

d. Understand - Identify everyone exhibiting higher-risk behaviours early in their risk journey.
e. Support - Interact with more customers and give the right level of support for each.

7. We also have a range of analytical models to identify signs of customer risk, as well as player protection tools that can be used by our customers. Details of those is set out below in our responses to the Coroner’s concerns.

8. Safer gambling is firmly embedded in Flutter’s culture. All employees, whether customer-facing or not, are required to participate in regular safer gambling training to ensure that they have an understanding of the area and the main indicators of problem gambling. Our Safer Gambling Strategy Team sends regular company-wide communications on progress in the safer gambling area, and there is a particular focus during Safer Gambling Week, with an array of events and talks.

9. Flutter currently has over 190 employees working in its Safer Gambling Operations Team (“SG Team”). The SG Team includes analysts and agents who assess customer behaviour and interact with those customers identified as being at higher risk. All of Flutter’s customer-facing employees are given ongoing training on safer gambling risks, starting with a three-week on-boarding course. These include internal training and external courses from organisations such as GamCare. All customer-facing employees therefore have an awareness of safer gambling risks when interacting with customers.

10. In particular, employees in the SG Team are given in-depth training on how to recognise problem gambling, how to respond to customers who may have said something of concern, and how to probe these comments effectively. The training courses have a particular focus on the skills required to manage difficult conversations with vulnerable customers, and are tailored to focus on the types of interactions our SG Team undertakes day-to-day. The training also deals with how the SG Team can look after their own mental health after dealing with difficult conversations with customers. Customer protection is the key emphasis in all of these training sessions.

11. Gambling is a leisure activity enjoyed by millions, with a small percentage of people suffering gambling- related harm. We are focussed on identifying and acting in relation to that minority, as set out in the rest of this response to the Report.

Changes since 2021

12. We have made a number of changes to our systems and controls since early 2021, the majority prior to becoming aware that Mr Ashton had taken his own life. Further detail can be found below in our responses to the concerns set out in the Report, but in summary, since 2021, we have:

a. introduced, in June 2021, a mandatory net deposit limit, of no more than £1,000 per month, for all customers returning from self-exclusion – anyone returning from a period of self-exclusion undergoes a safer gambling interaction and agrees an appropriate net deposit limit;

b. implemented checks with a credit reference agency, at defined levels of spend, to identify where customers are potentially financially vulnerable (including in respect of bankruptcy, county court judgements or the use of short-term loans) – if a customer is found to be potentially financially vulnerable a mandatory net deposit limit is applied to their account;

c. updated our predictive safer gambling model, which is based on the behaviours demonstrated by customers who later self-exclude, to include more factors (now totalling 370), including a greater weighting attributable to customers returning from self-exclusion;

d. introduced a mandatory net deposit limit, of no more than £500 per month, for all customers under the age of 25; and

e. imposed a stake limit of £10 on all online slots games.

It is impossible to know if these changes would have affected the tragic outcome in this case, but, as we explain later in this response, the changes at set out at (a) to (c) above would have had a significant effect on a customer displaying Mr Ashton’s betting activity now.

13. In addition to the changes already introduced since 2021, Flutter is committed to incorporating additional learnings from this case, and has already begun reviewing our controls and procedures to that end. Again, further detail is set out below, but in particular we have:

a. updated our “time spent on site” control so that as well as capturing customers who use our products for a significant period of time in any one day, we can identify and escalate cases where customers repeatedly use our products over a longer period; and

b. reviewed the patterns of play evident in Mr Ashton’s betting activity – such as the ‘sawtooth pattern’ identified by Professor Forrest – to incorporate learnings from this into future changes to our safer gambling models and controls.

14. Further, you will be aware that the Government issued a white paper on gambling reform on 27 April 2023 – “High stakes: gambling reform for the digital age” 1 (the “White Paper”). The White Paper includes significant changes to the regulatory environment in Great Britain, including the introduction of financial risk checks. We will be engaging with the Gambling Commission and the Government, which are both consulting on different aspects of the proposed changes.

Concern 1 – Player Protection Tools

15. Before we address your specific concern in relation to the safer gambling tools made available to customers (“Player Protection Tools”), we will briefly summarise the purpose of Player Protection Tools, how they work, and how they fit into our overall customer safety framework.

16. All remote gambling operators licensed in Great Britain must provide customers with a range of tools to help them gamble safely2. For example, tools that allow customers to set limits on their deposits or to exclude themselves from gambling. However, as set out in further detail below, Player Protection Tools are just one of a range of customer safety measures we utilise. They are designed to help customers regulate their play and budget, with stronger measures, like safer gambling interactions, undertaken when a customer’s risk escalates.

17. The White Paper recognises the important role that “player-centric tools”, such as the Player Protection Tools, can play in keeping customers safe. The White Paper also includes a review of such tools within the list of its key policy proposals and includes a plan to consult on and make changes to the use of such tools3:

“As with other sectors, we want consumers to be empowered to make informed decisions and manage spending. We will take the insights from behavioural science to make player-centric tools better. For instance, the Commission will consult on implementing potential improvements to player-set deposit limits such as making them mandatory or opt-out rather than opt-in, and we will continue work with the gambling and financial services sectors to make customer-controlled gambling transaction blocks as robust as possible.”4

18. The White Paper states the following in its conclusion in relation to these tools:

1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1153228/1286-HH-E02769112- Gambling_White_Paper_Book_Accessible1.pdf 2 https://www.gamblingcommission.gov.uk/standards/remote-gambling-and-software-technical-standards/rts-12-financial-limits 3 Ibid, page 13 4 Ibid, page 5

“In line with advice from the Gambling Commission, we believe player-centric controls such as pre- commitment tools and activity statements can be strengthened. The Commission will consult on requiring operators to improve these tools, such as by making deposit limit setting mandatory for all customers on account creation and pre-populating the limit with a reasonable default. It is also possible that other tools, such as the provision of clear information on annual and/ or account lifetime losses could be improved, for instance by being more accessible. The Commission will explore this further through a consultation to consider best practice on the design and use of player-centric tools before mandating implementation.”5

19. There are a range of Player Protection Tools that are available to Betfair’s customers. An overview of the Player Protection Tools that were available to Mr Ashton are set out in the table below:

Player Protection Tool Description Deposit limit A customer can set a limit on their deposits over a set time period Loss limit A customer can set a limit on their losses over a set time period Time Out A customer can take a short break of up to 30 days from our products during which time they cannot place any bets Reality check A customer can set an interval-based reminder of the length of time they have been playing Self-Exclusion A customer can completely block their account (for all products or just selected products) for longer periods of time, starting at six months and for up to five years. Customers can alternatively choose to permanently exclude from all or selected products. If they choose to permanently exclude from all products, their account will be closed and cannot be reactivated or re-opened

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. Whilst the use of Player Protection Tools has been steadily increasing across the industry in recent years as a result of the focus on safer gambling measures, Flutter has also taken steps to help increase their use amongst its customers. For example, when registering an account with Betfair, all new customers are required to set a deposit limit. The percentage of customers using Player Protection Tools far exceeds the small percentage of problem gamblers, highlighting the need to consider a variety of data inputs in any risk model.

21. In addition to the Player Protection Tools on Flutter’s websites and mobile applications, tools and services are available from third parties to help customers stop gambling altogether:

a. GAMSTOP: this is a multi-operator self-exclusion scheme that enables customers to simultaneously self-exclude from all operators licensed in Great Britain.

b. Banks and other payment providers: many UK retail banks, including all of the top five, offer customers the ability to opt-in to gambling blocks to prevent payments for gambling services.

c. Gambling blocking software: Services such as Gamban and BetBlocker allow customers to block access to gambling apps and websites on mobile devices.

5 Ibid, page 59, paragraph 97

Links to websites offering such tools and services are actively promoted on Flutter’s websites and mobile applications.

22. We note your concern that our Player Protection Tools are not adequate to protect “a problem gambler with a worsening problem” and that “such tools do not amount to any or any meaningful interaction with the gambler, or any intervention into the practices of the gambler”. Player Protection Tools are intended and designed to help customers control their gambling, which is the case for the vast majority of our customers who use these tools. They are, therefore, different from the interactions we carry out with customers.

23. As we explain in further detail in the next section (in relation to ‘Concern 2’), the trigger for interventions by Flutter, including for a human interaction, is dependent on an assessment of risk by our risk models. While we actively encourage all customers to use Player Protection Tools, we send safer gambling awareness emails tailored to a customer’s behaviour and the risks associated with the customer’s activity. The emails, which focus on education, highlight any changes in the customer’s gambling, as well as including details of the Player Protection Tools most appropriate to them. These safer gambling awareness emails are sent to customers that are deemed to be “low risk”.

24. Where a customer is deemed to be at a higher risk, that customer receives a “safer gambling interaction”, essentially a discussion with one of our trained staff from the SG Team. Between 1 January 2021 and 31 May 2023, our SG Team carried out 220,000 safer gambling interactions on Betfair alone. There are a number of actions we take after assessing a customer as higher risk, including suppressing marketing, exclusion from products, account suspensions, account closure (effectively enforced exclusion), and recommendations to use GAMSTOP (the industry-wide self-exclusion service).

25. Our evaluation of the latest Remote Customer Interaction Guidance from the Gambling Commission6 (issued in June 2022 and due to come into effect on 31 October 2023) is that we are expected to interact with no less than 6.8% of Betfair’s customers (taking into account the problem gambling rates for the relevant gambling activities). In its Remote Customer Interaction Guidance from July 2019, the Gambling Commission stated that “there are a number of ways for you to interact with your customers, including email, telephone calls, live chat or pop-up messages”. During 2021, Betfair interacted with 11.5% of its customers, almost double the expected rate under the 2023 guidance, and 2.1% of customers had a “human interaction” or enforced action in lieu of a completed interaction (e.g. a limit applied on their account).

26. The Health Survey for England 20187 (the “2018 Health Survey”) is the current source of official statistics on problem gambling rates used by the Gambling Commission8. The 2018 Health Survey estimated that 0.93% of gamblers could be defined as “problem gamblers”, amounting to 0.5% of the overall population9. Phone surveys undertaken by the Gambling Commission over the last 2 years estimated problem gambling rates in the range of 0.2% to 0.3%10.

27. On the subject of problem gambling rates, the inquest heard (from Professor Forrest) that the betting exchange is a product where, compared to “standard betting” (i.e. on a sportsbook), “a much higher proportion of customers were likely currently to be having problems with their gambling”. We heard a similar suggestion subsequently made at the Culture, Media and Sport Select Committee on 11 July 2023, where betting exchanges were said to have an “addiction rate” of 18%. These assertions appear to be based on an interpretation of results from the 2018 Health Survey, which shows estimated rates of problem gambling for people who participate in certain betting and gaming activities. However, these statements appear to be based on a misreading of results from the 2018 Health Survey, which estimated that 9.3% of

6https://assets.ctfassets.net/j16ev64qyf6l/4FF9PUgKMhXELzhIdTQlR5/da6f3ec33952e2325dacc5a862688638/Customer_Interaction_Formal_Guidance_R emote_gambling_licensees__June_2022_-_not_in_effect_.pdf 7 https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2018 8 “The Gambling Commission’s most robust sources of statistics on the prevalence of problem and at-risk gambling are the national health surveys” and the 2018 Health Survey contains “the latest health survey data”: https://www.gamblingcommission.gov.uk/about-us/guide/page/gambling-behaviour-2022- problem-and-at-risk-gambling. 9 54% of the population in England gambled in 2018 and 0.5% of the population “reached the threshold to be considered experiencing problem gambling” (https://www.gov.uk/government/publications/gambling-related-harms-evidence-review/gambling-related-harms-evidence-review-summary--2). 10 https://www.gamblingcommission.gov.uk/about-us/guide/page/gambling-behaviour-2015-to-2023-incidence-of-problem-gambling-short-form

people who participated in exchange betting were PGSI “problem gamblers” and 8.6% were PGSI “moderate risk” gamblers. Importantly, neither classification denotes “gambling addiction” or, to use the clinical term, “gambling disorder”. We note that “moderate risk” gamblers are defined in the PGSI as people “who may or may not have experienced adverse consequences from gambling”, while “problem gamblers” are defined as people “who have experienced adverse consequences from their gambling, and may have lost control of their behaviour”. These classifications are clearly distinct from “gambling disorder”, which is defined by the American Psychiatric Association (in the DSM-5) as follows: “The essential feature of gambling disorder is persistent and recurrent maladaptive behaviour that disrupts personal, family and/or vocational pursuits”.

28. Notably, the 2018 Health Survey shows a problem gambling rate of 0.0% for people whose only form of online gambling was betting exchanges. The data shows11 that it is only when betting exchange customers engage in multiple other forms of gambling, including spread betting, that a minority may then be classified as problem gamblers. We do not therefore believe it is reasonable to conclude that a betting exchange customer is higher risk based on the 2018 Health Survey. In the case of Mr Ashton, who had excluded from gaming products, almost the entirety of his betting activity on Betfair was on the betting exchange. Information on how Betfair’s betting exchange works is set out in the Appendix.

29. The analysis of the 2018 Health Survey data in relation to the problem gambling risk associated with betting exchanges is consistent with the analysis of our own data. Betfair is the world’s largest betting exchange, and we have access to a very large set of data points that consistently demonstrate that betting exchange activity is materially lower risk when compared to other gambling activities. For example, Betfair’s exchange customers have a self-exclusion rate of 1.7%; this is half the self-exclusion rate of Betfair's sportsbook customers.

30. In conclusion, we believe that Player Protection Tools play an important role in empowering customers and helping them to exercise control over their gambling. We will engage constructively with the Gambling Commission’s consultation in this area to help to strengthen and improve player-centric tools. We will also separately continue to work on strengthening and improving our Player Protection Tools and continue to actively encourage the use of these tools by all of our customers.

Concern 2 – The Algorithm

31. Again, before we address your specific concern in relation to our algorithm, it may be helpful to briefly summarise how Flutter’s safer gambling models operate.

32. We use a machine-learning algorithm to assess the gambling activity and behaviour of hundreds of thousands of our customers every day. We have to take a data-driven, risk-based approach when evaluating risk and identifying customers for interaction, as simple thresholds alone would not be helpful in identifying customers actually at risk and would generate an unmanageable volume of false positives. The challenge for Flutter, and indeed for all gambling operators, is to ensure that our safer gambling controls and models are as effective as possible in identifying customers that are experiencing, or that may be at risk of experiencing, gambling-related harm. Whilst no system can guarantee that every person that is at risk of experiencing gambling-related harm will be identified, protecting our customers from gambling-related harm is our biggest priority.

33. Our algorithm-based system was first introduced almost a decade ago, to both monitor harmful play and provide predictions on the likelihood of future risk. Our safer gambling teams continually monitor the effectiveness of our controls, regularly making changes to optimise their effectiveness. During this period we have seen significant and continuous improvements12. Our models combine the use of predictive

11 Albeit that relatively small sample sizes are used in the 2018 Health Survey. 12 Flutter uses a Transactional Risk Indicator Score (“TRI") to measure the percentage of revenues in a year from customers who subsequently go on to self-exclude (either directly with a Flutter brand or via GamStop) in that particular year. The reason for selecting this metric is that it can be applied across all customer revenue, and it has a strong correlation with PGSI scores (which by their nature can only be collected on a small sample basis). Each year Flutter targets a material reduction in TRI on a like-for-like basis vs. the previous year. As reported in Flutter Entertainment plc’s most recent Annual

controls and reactive behavioural controls, as well as financial and behavioural back stops tailored to a customer’s age.

34. Our safer gambling framework includes both proactive and reactive controls, focusing on behavioural and transactional risk indicators. There are two key elements to these controls: the predictive Customer Activity Awareness Programme (“CAAP”) model, and a reactive reporting suite. The two work in parallel to identify customers who may be at risk of experiencing gambling-related harm who are then assessed in more detail by members of the safer gambling team:

a. The predictive CAAP model currently monitors 370 data attributes every day for every customer and compares each customer’s behaviour to the patterns of behaviour of historical customers who later went on to self-exclude. Self-exclusion is a commonly used proxy for ‘problem gambling’ and allows us to predict the likelihood that a customer will experience gambling-related harm and intervene at an early stage.

b. Our reactive behavioural controls monitor customers, looking at their patterns of play against known markers of harm, such as spikes in deposits, stakes, time on site and overnight play.

35. Mr Ashton did not demonstrate many of the characteristics of customers who have issues with their gambling. For example, he:

a. almost exclusively used the Betfair Exchange which, as mentioned previously, is statistically the lowest risk gambling product (problem gambling rates are higher for those who use gaming products, and Mr Ashton had excluded from gaming in 2017);

b. never asked for free bets, complained to customer services, or used multiple payment methods (all of which can be signs of a problem gambler);

c. had minimal deposit volumes (on average, he deposited 1.5 times per week in the relevant period) and minimal methods for depositing; and

d. had a balance (i.e. a positive cash amount) in his Betfair account for extended periods of time.

36. For a number of reasons, including those set out above, Mr Ashton was classified as “low risk” by our safer gambling models. This meant that he received tailored safer gambling awareness emails when his gambling activity changed, rather than a “human interaction”, which an individual with a higher risk score would have received. Mr Ashton’s betting activity - including time spent on site, number and frequency of bets, and losses - were not remarkable when set against the rest of the Betfair Exchange customer base. Customers who bet on the Betfair Exchange are typically more sophisticated gamblers and can often place significant volumes of “back” and “lay” bets, often on the same markets.

37. We are constantly evolving and improving the CAAP model. For example, in 2022 we made a number of improvements to the operation of CAAP, including adding:

a. additional features incorporating inputs from a more diverse range of data sources across Flutter, including CRM data, customer service contacts, and more granular data relating to customer activity;

b. metrics which compare customers’ short-term activity to their longer-term average, and comparing their recent behaviour against their usual behaviour; and

c. features which ensure a customer’s self-exclusion history influences their risk score.

Report & Accounts 2022 (published on 9 March 2023), Flutter significantly exceeded the top end of the TRI target reduction range in 2022. As reported in the Annual Report & Accounts 2021 (published on 15 March 2022), Flutter also substantially exceeded the mid-point of the target range and was just short of the maximum TRI target in 2021. I.e. The data corroborates the very real progress being made across Flutter’s many Safer Gambling initiatives.

38. The CAAP model is regularly updated as new data becomes available to us and we build an ever deeper understanding of patterns that can indicate heightened player risk.

39. Our data science teams are currently analysing the behaviours outlined by in his report to assess whether any of these should be included in future iterations of our control framework (to the extent that they are not already included). By way of example, we have been looking at the “sawtooth” pattern of play and the deposit limit changes that were seen in Mr Ashton’s case to assess how they can be separated out from similar behaviour present in non-problem gamblers.

40. More specifically, and as mentioned above in the Introduction, we know that a customer in Mr Ashton’s circumstances – and repeating the same betting patterns - would be treated differently today due to specific improvements that have been made since early 2021. These include:

a. the imposition of a mandatory net deposit limit (that cannot be changed by the customer) of no more than £1,000 per month on every customer who returns from self-exclusion. For 96% of customers returning from a self-exclusion, we set this deposit limit at £500 a month or less (based on a review with the customer of their situation and affordability); and

b. ‘Financial Vulnerability Checks’ when a customer reaches defined net deposit thresholds. These checks are performed using a third-party credit reference agency to search for a history of bankruptcy, county court judgements, short-term loans and other markers of financial vulnerability. Looking back at Mr Ashton’s betting history during the period in question, such checks would have been undertaken on Mr Ashton on three separate occasions, and would potentially have led to the imposition of a net deposit limit of between £100 and £1,000 per month, depending on the outcome.

41. In terms of Mr Ashton’s betting activity, the changes described in the paragraph above would have significantly reduced his losses in Spring 2019 and March 2021.

42. To summarise, although our safer gambling models at the time categorised Mr Ashton as being at “low risk” of being likely to suffer gambling-related harm, we have made a number of changes to our controls since 2021 that mean it would be impossible for a customer in Mr Ashton’s situation to repeat the same pattern of losses today.

Concern 3 – Industry (Regulatory) Standards

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.

44. Contrary to assertions made during the inquest, there is no specific “minimum standard.” Neither does an objective measure of “good” or “best” practice exist. Instead, gambling operators put in place controls designed to comply with the LCCPs. The Gambling Commission, in its role as regulator, carries our regular inspections of its licensees to ensure compliance with LCCPs, and also recommends areas for improvement based upon its learnings from across the industry. Where it believes a licensee is not complying with the LCCPs, the Gambling Commission takes action, including in the form of improvement notices, the “special measures” process, regulatory settlements, fines and licence suspensions.

45. Flutter takes its responsibility to protect our customers very seriously. We always aim to go beyond mere

compliance with regulatory standards. For example, we are involved in the industry data sharing project, GamProtect, which is a pilot aimed at sharing details of some of the highest risk customers across major operators. All of our UK-facing brands – Betfair, Paddy Power, Sky Betting & Gaming, and tombola – are rated ‘Advanced Level 3’, which is the highest level possible, by GamCare (the leading independent assessor of safer gambling standards).

46. We also lead the industry in introducing new controls. For example, in 2021 we became the only operator to proactively introduce a £10 stake limit on online slots games across our brands: an approach which has recently been included in the White Paper recommendations. In 2022, Flutter also mandated a strict maximum monthly net deposit limit of £/€ 500 for all customers under the age of 25 in the UK and Ireland. Using internal and external data, we established that younger customers can experience higher levels of problem gambling rates compared to older customers. Our assessment of the data demonstrated that younger people can be more vulnerable to experiencing gambling harm due to a number of factors, such as achieving independence from their parents and leaving the family home, increased financial independence coupled with lower levels of discretionary income, and the broader societal impacts that come with change in lifestyle such as working, attending university, and increased use of social media. As such, we challenged ourselves to go further in protecting our younger customers during this time of change, and we became the first operator to mandate maximum deposit limits as an additional safety net for our younger customers.

47. Accordingly, in our view, if there is any “best” practice in gambling regulation anywhere in the world, it is the work we are doing, along with other major operators and regularly discussed with the Gambling Commission, in the British market.

48. It is important to note that customer safety is a constantly evolving area. There will always be more that we can learn and, as a result of Professor Forrest’s report into Mr Ashton’s patterns of play and our own review of Mr Ashton’s gambling activity, we pro-actively made some changes ahead of the inquest, which included:

a. Time Spent on Site Escalation Control: We made improvements to our ‘Time Spent on Site’ control designed to capture where the duration of a customer’s play could be a cause for concern. We have strengthened this control to ensure that its focus is broader than isolated sessions of a significant amount of time. The improved control now also identifies customers who spend a more moderate amount of time on site, but do so on repeated occasions. Where a customer triggers the relevant threshold, they are escalated for a human review of their activity. We are also exploring how we can make further improvements in this area. For example, we are looking at displaying time spent on site to both our customers and our customer service agents, and enabling the ability to set maximum session caps (in addition to the Reality Check tools we already have in place) in order to increase customer awareness and the effectiveness of our interventions.

b. Backdating Self-Excluded returner limits: In June 2021, we introduced a deposit limit for customers returning from self-exclusion. This limit is mandatory and set at a maximum of £1,000 per month for over 25s, and £500 per month for those under 25. When we initially introduced this control, it was a forward-looking control applied to customers who subsequently returned from self-exclusion. However, with additional data now available, we have since updated this control to any account returning from self-exclusion from 1 November 2019 onwards. This led to us applying the maximum mandatory deposit limits set out above to an additional 6,000 customer accounts, who returned from self-exclusion between November 2019 and July 2021.

49. Finally, we note the following in respect of British gambling regulation:

a. the LCCPs, particularly around customer interaction, have changed since the period in question, materially strengthening customer protections;

b. the Government has, over the last three years, undertaken the most detailed review of gambling policy and regulation in almost 20 years, and proposed a significant number of changes, many designed to further increase customer protections, in the very detailed White Paper; and

c. the Gambling Commission is now consulting on those proposed changes with the aim of introducing specific changes in the next one to two years.

Conclusion

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. We will continue to work with the Government, the Gambling Commission, acknowledged experts in this area and others in the industry to ensure that our services are as safe as they can be for our customers.

51. We hope this response is helpful in explaining the work Flutter is doing related to the concerns raised in the Report and sufficiently addresses them. If, however, further information or clarification would be of assistance, we will, of course, endeavour to assist.

Dear Coroner Cartwright

Response to Regulation 28 Report to Prevent Deaths – Luke Anthony Ashton

1. This letter is sent on behalf of Mr Andrew Rhodes, Chief Executive Officer of the Gambling Commission (“the Commission”) in response to the Regulation 28 Report to Prevent Future Deaths (“the Report”) of 12 July 2023.

2. Mr Rhodes and the Commission wish to extend our sincere condolences and deepest sympathies to Mr Ashton’s family following his tragic death. We are committed to protecting people from gambling harm and welcome the views of the Coroner as an opportunity to reflect upon the areas identified as concerns and to ensure appropriate action is taken to prevent future deaths.

3. The Report arises from the inquest into the death of Luke Anthony Ashton (“Mr Ashton”) that concluded on 29 June 2023. The Coroner concluded that the evidence showed that Mr Ashton was suffering from a gambling disorder which contributed to his decision to take his own life and that opportunities were missed by the operator, Betfair, which may have possibly changed the outcome for Mr Ashton. The Report identifies three matters of concern, namely:

(i) the inadequacy of player protection tools as a means to protect a person such as Mr Ashton who was a problem gambler; (ii) the failure of the algorithm devised and operated by Betfair to identify Mr Ashton as a problem gambler; and (iii) Betfair’s understanding of its responsibilities with regard to gambling customers.

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4. I hope the contents of this response will assist the Coroner in understanding the action which has been taken by the Commission together with identifying future work intended to strengthen regulation to protect customers from gambling harm. This response is structured as follows:

a) Background: An overview of the system of gambling regulation and the role of the Commission. b) The Commission’s ongoing work to strengthen regulation to protect consumers from gambling harm. c) The Commission’s response to the specific matters of concern identified in the Report. d) Annex detailing additional information about the Commission’s role in reducing gambling harm.

A. Background: Overview of the system of gambling regulation and the role of the Commission
5. The Commission was set up in 2007 to regulate commercial gambling in Great Britain in partnership with licensing authorities. It is an executive non-departmental body sponsored by the Department for Culture, Media and Sport (“DCMS”).

6. The primary legislation governing gambling (excluding the National Lottery) is the Gambling Act 2005 (as amended) (“the Act”). It provides for the licensing of gambling operators and individuals working within the gambling industry.

7. Some of the Commission’s principal functions under the Act include:

a. To license gambling operators by way of operating licences under Part 5 of the Act. Consideration of an application for an operating licence involves detailed analysis of the applicant’s suitability to carry on the licensed activities, its integrity, competence, financial circumstances and so on. Key to this is its systems for protecting vulnerable people and ability to meet the requirements of the Licence Conditions and Codes of Practice (“LCCP”).

b. The preparation, publication, and review, of a statement that sets out the principles which will govern the exercise of its functions, and, in particular, explains how such principles will assist the Commission in its pursuit of the licensing objectives. The Commission publishes a number of key documents that set out the responsibilities of those that hold

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operating or personal licences and our approach in regulating the gambling sector. The suite of documents includes, for example ‘Statement of Principles for Licensing and Regulation1’, ‘Licensing, Compliance and Enforcement Policy Statement2’, ‘Indicative Sanctions Guidance3’ and ‘Statement of Principles for determining Financial Penalties4’.

c. Setting the rules with which licence holders must comply. The majority of these rules take the form of licence conditions and are set out in the LCCP5.

d. To undertake activities for the purpose of assessing compliance with the LCCP, provisions of the Act, or whether an offence has been committed under the Act.

e. To take regulatory action against an operating or personal licence holder by way of exercising its powers to commence a formal investigation, to commence a licence review under section 116, to issue a formal warning, to attach, remove or amend a licence condition, to suspend or revoke a licence, and to impose a financial penalty.

f. The power to investigate whether an offence has been committed under the Act, and to pursue criminal proceedings if this is the case.

8. In exercising the statutory functions set out above, the Commission must aim (a) to pursue and, wherever appropriate have regard to, the licensing objectives and (b) to permit gambling in so far as it thinks it reasonably consistent with pursuit of the licensing objectives (section 22 of the Act). The licensing objectives, set out in section 1 of the Act, are: “a) preventing gambling from being a source of crime or disorder, being associated with crime or disorder, or being used to support crime, b) ensuring that gambling is conducted in a fair and open way; and c) protecting children and other vulnerable persons from being harmed or exploited by gambling.”

1 Gambling Commission Statement of principles for licensing and regulation 2 Licensing, compliance and enforcement under the Gambling Act 2005 (gamblingcommission.gov.uk) 3 Indicative sanctions guidance - June 2017 (ctfassets.net) 4 Statement of principles for determining financial penalties (gamblingcommission.gov.uk) 5 Licence Conditions and Codes of Practice (gamblingcommission.gov.uk)

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9. As to section 1(c), “vulnerable” is not defined in the Act but the Commission has set out a non-exhaustive definition in the Statement of Principles for Licensing and Regulation, which it is required to publish under section 3 of the Act, which states at paragraph 5.26: “With regard to ‘vulnerable persons’, whilst the following list is not exhaustive, the Commission considers that this group will include:
• people who spend more money and/or time gambling than they want to
• people who gamble beyond their means
• people who may not be able to make informed or balanced decisions about gambling, for example because of health problems, learning disability, or substance misuse relating to alcohol or drugs.”
10. The Commission’s view is that persons who are addicted to gambling or suffering from a gambling disorder would be ‘vulnerable persons’.

11. The Commission has further set out in corporate documents, such as our Strategy plan: 2018 to 20216, what we mean by vulnerability, namely ‘A customer in a vulnerable situation is somebody who, due to their personal circumstances, is especially susceptible to detriment, particularly where a business is not acting with appropriate levels of care.'

12. In July 2023 the Commission published a Vulnerability Statement setting out our approach to identifying, supporting and protecting consumers who are in vulnerable situations7. It brings together information from existing Commission policy and guidance documents to help provide consolidated information about how we take account of customer vulnerability in our work. It is intended to help gambling businesses, gambling consumers, the general public and other regulators and organisations understand our approach and expectations. It references the Commission’s explanation of what we mean when we discuss vulnerability, provides information about our approach to building understanding of factors which may make a consumer more vulnerable to gambling harm and explains how we set requirements for gambling businesses to support, identify and protect vulnerable consumers. We will continue to assess the insights and evidence concerning consumer vulnerability and may make changes to our approach over time. Further information can be found here: What do we mean by vulnerability? (gamblingcommission.gov.uk).

6 Strategy plan: 2018 to 2021 (gamblingcommission.gov.uk) 7 Vulnerability statement (gamblingcommission.gov.uk)

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Social responsibility in the LCCP
13. Pursuant to its duties and powers under the Act, the Commission sets out its requirements and expectations of operators in its LCCP which set licence conditions, code of practice (“Code”) and social responsibility code provisions (“SR Code”).

14. In the LCCP the Commission sets out important duties on operating licence holders, including duties in relation to the protection of vulnerable persons. For example, the LCCP includes duties in respect of advertising of gambling, customer interaction when indicators of harm are present, and the provision of facilities for customers to self-exclude from gambling. This document is kept under review and updated periodically. I address below those aspects of the LCCP which specifically relate to the concerns identified in the Report.
15. The Commission also publishes a variety of guidance, advice and technical standards. This includes guidance, for example, aimed at helping potential applicants understand what licence they might require, helping licensees comply with their regulatory obligations (such as the customer interaction guidance mentioned later in this response), and reactive guidance aimed at helping the sector navigate situations such as the Covid-19 pandemic8. In some instances, operators are required to take into account guidance published by the Commission (for example, SR Code 3.4.1 and 3.4.3. require operators to take into account the Commission’s guidance on customer interaction, which I explain in further detail below).
16. Failure to comply with any of the requirements of the LCCP, including the SR Code, can lead to the commencement of a section 116 licence review, which may culminate in the imposition of a formal sanction which might include licence revocation. In addition, it is an offence under section 33 of the Act to provide facilities for gambling other than in accordance with the terms and conditions of a licence, meaning that a failure to comply with the LCCP can have grave consequences for operators and associated individuals.

The Commission’s approach to compliance and enforcement under the Act

17. The Commission regulates in the region of 2500 licensees offering land based and online products. It receives significant amounts of data from licensees every year and has access to other sources of data such as complaints, media coverage and intelligence reports. The Commission operates a risk-based approach to assessing licensees in accordance with the

8 Customer interaction – Additional formal guidance for remote operators during Covid-19 outbreak (gamblingcommission.gov.uk)

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approach set out in the Statement of Principles for Licensing and Regulation and Licensing and Compliance and Enforcement Policy Statement.

18. The Commission’s approach to compliance has to balance maintaining and improving standards across the sector, while retaining sufficient agility and flexibility to respond to new issues, concerns and intelligence.

19. The Commission operates a 3-year cycle of assessment for the largest operators where there are no emerging concerns about their compliance. The assessment takes the form of a compliance assessment undertaken by the Commission9. Where there are concerns about compliance, the Commission will engage more frequently and, where needed, at pace. The Commission operates a programme to triage data received about licensees, and to identify at the earliest opportunity any factors of risk that may indicate compliance engagement is required.

20. Compliance engagement ranges from conducting full in-depth assessments of both land based and online licensees, to conducting more focussed assessments of specific areas of a business including desktop reviews of websites, app-based products and a review of online promotions and social media presence. The Commission also conducts thematic projects and raising standards educational activity for licensees, which can consist of premises visits, reviews of policy documents, interviews with a licensees’ key staff, observation of practices, review of customer records and assessment of internal controls. The Commission also conducts educational activities such as creating podcasts, conducting workshops and offering access to an account manager for compliance contact.

21. Between July 2022 and July 2023, the Commission’s compliance team conducted 117 assessments of operating licences, 136 Premises Assessments and 101 website reviews. This activity assessed large, medium and some smaller operators offering land based and online products.

22. When an assessment has been carried out, the licensee will be notified of the result and any further action that should be taken, as soon as possible. If serious failings are revealed during or because of a compliance assessment, then the Commission may decide that it is

9 Further information is available here: https://www.gamblingcommission.gov.uk/licensees-and- businesses/guide/compliance-assessments

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appropriate to place the licensee into Special Measures or consider taking formal enforcement action.

23. The objective of the Special Measures regime is to raise standards immediately through strict supervision by the Commission of improvements being made by the licensee to remedy failings. As is set out in the Licensing, Compliance and Enforcement Policy Statement, the effect of Special Measures is that the licensee will be invited to submit to and agree with the Commission an urgent action plan to rectify the regulatory failings identified. This may include divestment of any financial benefits derived from the failings. If the licensee fails to agree an action plan, or fails to implement the agreed action plan, the Commission may proceed to review the licence or commence a regulatory investigation which may lead to enforcement action such as a penalty or revocation of the licence. Compliance with the action plan does not prevent the Commission from reviewing the licence and taking enforcement action in any event, but such compliance with the action plan would be treated as a mitigating factor. Where the licensee has fully complied with the action plan, it may request release from Special Measures. The Commission will consider such a request following a further compliance assessment.

24. In cases where compliance action, be that Special Measures or some other action, has not led to the desired change in a licensee or in instances where further possible failings are brought to the attention of the Commission, the Commission may escalate this and commence formal enforcement action.

25. Under the Act, the Commission has the power to commence formal regulatory enforcement action against licensees (both operating licensees and personal licensees) to review their licences and the operation of licence conditions. The powers allow the Commission to issue a formal warning, to attach, remove or amend a licence condition, to suspend or revoke a licence, and to impose a financial penalty. The Commission will review licences under section 116 where it considers it an effective and proportionate use of its enforcement powers.

26. In deciding whether to exercise the Commission’s regulatory powers, the Commission has regard to the risk to the licensing objectives and applies the principle of proportionality. This includes taking into consideration the factors set out in our Enforcement Policy, for example mitigating and aggravating factors in relation to the seriousness of the matters under consideration.

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27. Where appropriate, in certain specific cases, the Commission may seek to fulfil its statutory obligations and pursue the licensing objectives by means that stop short of a formal licence review under section 116 of the Act. One means of achieving this is by way of regulatory settlement. Regulatory settlements are only considered in certain circumstances, for example where the licensee is open and transparent, able to demonstrate that they have insight into the apparent failings, prepared to divest itself of any gross gambling yield or costs savings which have accrued as a result of the failings and prepared to follow advice and implement procedures to ensure there is no repetition. The purpose of settlements is not for licensees to avoid responsibility for breaches – instead, they are a more efficient way to resolve matters when the Commission considers an equivalent regulatory outcome can be achieved.

28. Since 1 April 2019 the Commission has concluded over 350 enforcement cases with operators paying over £159 million in financial penalties and regulatory settlements.

29. In addition to its compliance and enforcement work, the Commission works with a wide range of other regulators, public health bodies, the third sector and businesses to reduce gambling related harms. We have included information about this engagement, as well as other areas of work we believe may be relevant, in the Annex to this response.

B. The Commission’s work to strengthen regulation to protect consumers from gambling harm

30. Before turning to the three specific concerns identified in the Report, it may be useful to outline by way of an overview the work which has been undertaken by the Commission in recent years to strength regulation specifically in the context of seeking to protect consumers from gambling harm.

31. The Commission has undertaken a significant programme of work over the last five years which spans each stage of the customer journey from making a decision to gamble including strengthening age and verification controls at registration, to introducing new requirements to limit intensity of online slot gambling during gambling, to stricter controls on gambling marketing before during and after gambling, all with the objective of reducing gambling harm. This approach of ensuring protections are in place at each stage of the customer journey is key to reducing the risk of harm - it is important that games and products are safe, that marketing is undertaken responsibly, that tools are available to support customers to manage

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their gambling and that operators are able to identify customers at risk of harm and that interventions/interactions with customers are effective. During this period, we have introduced the following key controls, the last three of which were introduced after April 2021:

a. In 2018, stricter LCCP requirements were introduced around marketing of offers, ensuring we have powers to take action where operators breach the UK Advertising Codes, specifying that operators must not send direct e-marketing to consumers without their informed and specific consent, and that operators must ensure that their terms and conditions are not unfair (as defined in the Consumer Rights Act 2015). Our collaborative work with the Competition and Markets Authority (“CMA”) and the Advertising Standards Authority (“ASA”) on unfair terms and misleading practices, which concluded in 2018, saw major changes and improved standards in the online sector on the fairness and openness of promotional offers10.
b. In May 2019, we strengthened age and identity verification controls. This included a new requirement that operators must complete age verification on all customers before they can deposit money and gamble or access play for-free games11.
c. In April 2020 we introduced a ban on gambling with credit cards to reduce the risk of people gambling with money they do not have, accumulating debt and experiencing financial harms. The ban was introduced in response to evidence that some gamblers with high levels of debt were using credit cards to facilitate their gambling behaviour. We published the interim evaluation of the credit card ban in November 2021 which indicated that the action is supported by consumers and has not resulted in harmful consequences12.
d. In October 2020, we introduced new LCCP requirements13 and associated guidance to reduce harms experienced by High Value Customers (known as VIPs) and, more generally, those consumers that provide disproportionate financial value to licensees14. The measures were introduced as part of the Commission’s work to strengthen consumer protection and have led to an estimated 90 percent reduction in customers signed up to such ‘VIP’ schemes.
e. In October 2021 we introduced new rules into the Remote Gambling and Software Technical Standards (“RTS”) for online slots on game speed and banning features which increase the intensity of gaming15. In June 2023 we published an assessment of the

10 Joint CMA and Gambling Commission letter to the gambling sector, April 2019 11 New age and identity verification rules - changes to the LCCP from Tuesday 7 May (gamblingcommission.gov.uk) 12 Prohibition of gambling on credit cards report (gamblingcommission.gov.uk), November 2021 13 Social responsibility code provision 5.1.1 – Cash and cash equivalents 14 New rules to stamp out irresponsible ‘VIP customer’ practices (gamblingcommission.gov.uk), September 2020 15 Gambling Commission announces package of changes which make online games safer by design, February 2021

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impact of these online game changes for slots products which indicated that it has resulted in reduced play intensity and that it has not resulted in harmful unintended consequences16.
f. In October 2021, a ban on functionality which enabled reverse withdrawals was introduced to protect customers and support customer decisions to withdraw their funds from gambling17.
g. Further requirements on operators to identify customers at risk of harm and take action in respect of customers identified at risk of harm came into effect in September 2022 and February 202318. The new rules are stronger and more prescriptive, including by requiring operators to monitor a specific range of indicators, as a minimum, to identify gambling harm, flag them and take action. Further information on these requirements is included in paragraphs 46 and 47 when setting out information related to Concern 1.

32. On 28 February 2023 the Commission commenced a consultation on proposed changes to certain requirements on gambling businesses aimed at improving player protection19. These are:

a. Reporting deaths by suicide to the Commission: We have proposed that licensees are required notify us when they become aware that a person who has gambled with them has died by suicide, building on existing good practice. While some licensees have notified us in this way in the past, there is a risk that this is not being done consistently. As such, we are consulting on introducing a specific requirement which puts this expectation beyond doubt. The reporting of this information enables us to assess the licensee’s compliance with conditions of its licence and helps to inform our ongoing consideration of policy (for example, policies regarding customer interaction, the use of gambling management tools and our knowledge of gambling across multiple operators).

b. Extending the multi-operator self-exclusion scheme to additional categories of betting licensee: Self-exclusion is an important and effective tool for people who wish to be supported to stop gambling. Nearly 400,000 consumers have used GAMSTOP, the national online self-exclusion scheme, to self-exclude themselves from all online gambling

16 Assessment of Online Games Design changes (gamblingcommission.gov.uk), June 2023 17 Gambling Commission announces package of changes which make online games safer by design, February 2021 18 LCCP Condition 3.4.3 - Remote customer interaction (gamblingcommission.gov.uk) 19 Consultation on Licence conditions and codes of practice February 2023: multi-operator self-exclusion, notification of deaths by suicide and technical update relating to payment services - The Gambling Commission - Citizen Space. The consultation closed 23 May 2023; We are currently analysing responses to the consultation. We expect to publish the outcome of the consultation in autumn 2023.

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licensed by the Commission. Most gambling businesses offering remote betting are required to participate in an online multi-operator self-exclusion scheme known as GAMSTOP. Where a customer signs up to GAMSTOP, they will automatically be self- excluded from all online gambling offered by all operators who participate in the scheme. The Commission has recently consulted to extend the requirement to participate in the GAMSTOP scheme to all licensees that make and accept bets by telephone and email, including for example betting via social media messaging apps.
33. In addition, we are supporting the owners of multi-operator self-exclusion schemes to consider how they can improve the effectiveness of their schemes, from making it straightforward to request self-exclusion from the multiple sectors to considering how best to improve identification.

34. In April 2023, the Commission advised the Government on its review of the Gambling Act
200520. In April 2023 the Government published its white paper following the 'High Stakes: Gambling for the Digital Age', outlining a comprehensive package of new protections to help safeguard customers against gambling related harm21. Consistent with our advice, the proposed new measures include further protections to apply at each stage of the customer journey, which will make gambling products inherently safer but also support and empower customers to control and manage their gambling and to seek redress where things go wrong.

35. As part of this programme of work connected with the Gambling Act Review, the Commission is also seeking to consult on a significant package of measures to strengthen player protection in the context of online gambling (to include identification of financially vulnerable customers and to tackle significant unaffordable binges and significant unaffordable gambling losses over time, alongside increased protections for young adults) and restrictions on bonus offers.

36. On 26 July 2023, we issued our first consultation connected with this work, which included a series of proposed changes to our requirements on gambling businesses, through the LCCP and the RTS22:

20 Advice to Government - Review of the Gambling Act 2005 (gamblingcommission.gov.uk), April 2023 21 High Stakes: Gambling Reform for the Digital Age (publishing.service.gov.uk), April 2023 22 Summer 2023 consultation on proposed changes to Licence Conditions and Codes of Practice (LCCP), Remote Gambling and Software Technical Standards (RTS), and arrangements for Regulatory Panels - The Gambling Commission - Citizen Space. The closing date for this consultation is 18 October 2023.

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a) Remote gambling: financial vulnerability and financial risk. We are currently consulting further on customer interaction and specifically how operators identify customers at risk of financial harm. This consultation focusses on financially vulnerable customers, tackling binge gambling and significant unaffordable losses over time, working with Government. While we are proposing new specific requirements on operators in relation to financial risk, we stress operators should use all of the information obtained within their overall customer interaction approach to identify risk of harm and take action to prevent gambling harm.

b) Improving consumer choice on direct marketing. We want to empower customers by giving them more control over the direct gambling marketing they wish to receive. We are consulting on introducing a new LCCP requirement to provide customers with options to opt-in to the product type they are interested in and the channels through which they wish to receive marketing.

c) Strengthening age verification in premises: We are also consulting on how licensees make sure they have effective age verification procedures where their premises may not be directly supervised.

d) Remote game design: We are consulting on a series of changes to existing Remote Gambling and Software Technical Standards and new requirements, in order to reduce the speed and intensity on online products while making them fairer and increasing consumer understanding about game play. We also propose removing features which can speed up play to reduce the harm experienced by consumers who are gambling particularly quickly or intensely. Another proposal seeks to remove features which may mislead consumers or create dissociation from awareness of play.

37. On 26 July 2023 the Government separately launched a consultation23 connected with the Gambling Act Review in relation to remote gambling. This consultation set out proposals for the introduction of online slot stake limits to curb harmful gambling as online slot games are deemed a higher-risk gambling product, associated with large losses, long sessions and binge play.

38. The Commission is intending to continue this programme of work with a consultation this winter on proposals relating to the role of player-centric controls, in particular the role of

23 Consultation on proposals for a maximum stake limit for online slots games - GOV.UK (www.gov.uk)

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deposit limits and the extent to which such gambling management tools should be encouraged or mandated; and on proposals relating to ensuring that any inducements or bonus offers are offered responsibly to consumers to reduce the risk of harm.

C. The Commission’s response to the specific matters of concern set out in the Report

Concern I: The player protection tools used by Mr Ashton were and are inadequate to protect a person such as him, who was a problem gambler and 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.

Response to Concern 1 insofar as it pertains to the whole of the gambling industry

39. As part of introducing protections at each stage of the customer journey, the Commission seeks to impose requirements to ensure that a range of tools are available to customers to support customers to gamble safely. These are tools which are offered from the point of registration with an online account in order to support a customer to manage, limit or stop gambling with for a period of time.
40. The Commission requires operators to offer such gambling management tools, also known as player protection tools, through both the section of LCCP that covers the protection of children and other vulnerable individuals and our remote gambling and software technical requirements (“RTS”)24. These measures were all in place during the time that Mr Ashton was gambling with Betfair, and include: a) Self-exclusion, the facility for a customer to request that the gambling operator prevents them from gambling for at least six months and ceases all marketing activity until the customer opts back in. This is required by SRCP 3.5.3 and Ordinary Code
3.5.4 and was introduced in 2007. b) Time-out, a facility for a customer to request that the gambling operator prevents them from gambling for a shorter period of time e.g., around pay day. This is required by SRCP 3.3.4 and was introduced in 2015. c) Financial limit setting, a facility to assist a customer in sticking to their personal budgets for gambling with the operator. This is required by the RTS, and the requirement has been amended over time.

24 Remote gambling and software technical standards (RTS) (gamblingcommission.gov.uk)

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d) Time requirements, to provide customers with facilities to assist them to keep track of the time they spend gambling. This is required by the RTS, and the requirement has been amended over time.

41. Our programme of work connected with the Gambling Act Review includes work to further increase take-up of gambling management tools through proposed requirements on the visibility and presentation of these tools, and proposed requirements about how the tools are constructed for maximum efficacy. Further information is set out at paragraphs 34-38 above.

42. These tools are an important part of the regulatory framework, but they are primarily preventive in nature. As part of the wider framework, it is important that further controls are in place to support customers who are at risk of harm, and in particular those customers who due to gambling disorder or other reasons will find it hardest to use such tools. Therefore, the LCCP also places obligations on operators to protect consumers from harm, including imposing an obligation to take steps to identify customers at risk of harm and interact with customers which go beyond offering them player protection tools to use.

43. Between October 2019 and September 2022, the customer interaction requirements that were in place for remote operators were set out in the contemporaneous version of LCCP, specifically SR Code 3.4.1 which stated:

1. Licensees must interact with customers in a way which minimises the risk of customers experiencing harms associated with gambling. This must include:
a. identifying customers who may be at risk of or experiencing harms associated with gambling.
b. interacting with customers who may be at risk of or experiencing harms associated with gambling.
c. understanding the impact of the interaction on the customer, and the effectiveness of the Licensee’s actions and approach.

2. Licensees must take into account the Commission’s guidance on customer interaction.

44. The guidance referred to was in effect from October 2019 to September 2022 and can be found here25. The guidance set out why customer interaction is a requirement, made clear the Commission’s expectations in terms of the steps required of licensees to identify and interact with customers at risk of harm and suggested ways that licensees could meet them.

25 Customer_Interaction_Formal_Guidance_Remote_operators__July_2019_-_no_longer_in_effect_.pdf (ctfassets.net)

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45. The purpose of the guidance was to share knowledge based on research, current practice (at the time) and lessons learned in order to support licensees in determining how they can meet the three key requirements set out in SR Code 3.4.1 in relation to customer interaction: to identify, interact and evaluate.

46. In November 2020 the Commission consulted26 on the introduction of stronger LCCP requirements to help ensure remote gambling operators do more to identify consumers who may be harmed by gambling and to interact and take action sufficiently early and effectively to prevent harm. Following consultation, in September 2022 we introduced the majority of strengthened customer interaction requirements for remote operators. The applicable provision became SR Code 3.4.3 and is set out below:

1. Licensees must implement effective customer interaction systems and processes in a way which minimises the risk of customers experiencing harms associated with gambling. These systems and processes must embed the three elements of customer interaction – identify, act and evaluate – and which reflect that customer interaction is an ongoing process as explained in the Commission’s guidance (see paragraph 2).
2. Licensees must take into account the Commission’s guidance on customer interaction for remote operators as published and revised from time to time (‘the Guidance’). 
3. Licensees must consider the factors that might make a customer more vulnerable to experiencing gambling harms and implement systems and processes to take appropriate and timely action where indicators of vulnerability are identified. Licensees must take account of the Commission’s approach to vulnerability as set out in the Commission’s Guidance.
4. Licensees must have in place effective systems and processes to monitor customer activity to identify harm or potential harm associated with gambling, from the point when an account is opened. 
5. Licensees must use a range of indicators relevant to their customer and the nature of the gambling facilities provided in order to identify harm or potential harm associated with gambling. These must include: o
a. customer spend o
b. patterns of spend o
c. time spent gambling o
d. gambling behaviour indicators o
e. customer-led contact

26 Remote customer interaction - Consultation and Call for Evidence - The Gambling Commission - Citizen Space. This consultation closed on 9 February 2021. Our response was published on 14 April 2022.

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o
f. use of gambling management tools o
g. account indicators.
6. In accordance with SR Code Provision 1.1.2, licensees are responsible for ensuring compliance with the requirements. In particular, if the licensee contracts with third party business-to-business providers to offer any aspect of the licensee’s business related to the licensed activities, the licensee is responsible for ensuring that systems and processes are in place to monitor the activity on the account for each of the indicators in paragraph 5 (a-g) and in a timely way as set out in paragraphs 7 and 8.
7. A licensee’s systems and processes for customer interaction must flag indicators of risk of harm in a timely manner for manual intervention, and feed into automated processes as required by paragraph 11. 
8. Licensees must take appropriate action in a timely manner when they have identified the risk of harm. 
9. Licensees must tailor the type of action they take based on the number and level of indicators of harm exhibited. This must include, but not be limited to, systems and processes which deliver: o
a. tailored action at lower levels of indicators of harm which seeks to minimise future harm o
b. increasing action where earlier stages have not had the impact required o
c. strong or stronger action as the immediate next step in cases where that is appropriate, rather than increasing action gradually o
d. reducing or preventing marketing or the take-up of new bonus offers where appropriate o
e. ending the business relationship where necessary.
10. Licensees must prevent marketing and the take up of new bonus offers where strong indicators of harm, as defined within the licensee’s processes, have been identified.
11. Licensees must ensure that strong indicators of harm, as defined within the licensee’s processes, are acted on in a timely manner by implementing automated processes. Where such automated processes are applied, the licensee must manually review their operation in each individual customer’s case and the licensee must allow the customer the opportunity to contest any automated decision which affects them.
12. Licensees must implement processes to understand the impact of individual interactions and actions on a customer’s behaviour, the continued risk of harm and therefore whether and, if so, what further action is needed.  
13. Licensees must take all reasonable steps to evaluate the effectiveness of their overall approach, for example by trialling and measuring impact, and be able to demonstrate to the Commission the outcomes of their evaluation.

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14. Licensees must take account of problem gambling rates for the relevant gambling activity as published by the Commission27, in order to check whether the number of customer interactions is, at a minimum, in line with this level. For the avoidance of doubt, this provision is not intended to mandate the outcome of those customer interactions.

47. Requirement 10 came into force on 12 February 2023 and the Requirements which directly cross-refer to the guidance will come into force on 31 October 2023. The guidance associated with SR Code 3.4.3 was published on 23 August 202328.

48. Further, as indicated at paragraph 36, the Commission is currently consulting further on customer interaction requirements and how operators identify customers at risk of financial harm, with a focus on financially vulnerable customers, and tackling binge gambling and significant unaffordable gambling over time, working with Government.

49. The Commission hopes that the Coroner can be assured that, as part of its ongoing drive to improve standards of player protection in the gambling industry, the Commission has brought about and continues to bring about higher standards across the industry through its rules about customer interaction and supporting guidance.

Response to Concern 1 insofar as it relates to Betfair

50. The Commission understands that Concern 1 relates to the adequacy and efficacy of both player protection tools (for example, deposit limits and self-exclusion) and Betfair’s interactions with Mr Ashton, in particular in the period between July 2019 and 22 April 2021.

51. The regulatory requirements in relation to these areas at the time Mr Ashton was gambling with Betfair are set out above at paragraphs 43-45.

52. In December 2020 the Commission’s compliance team conducted an assessment of a number of licensees within the Flutter Group, including the Betfair brand. As part of that assessment, we assessed the controls those licensees had in place around identifying those at risk of potential gambling related harm and the measures in place for customer interaction. Our findings from that assessment indicated that there were failings in the processes for identifying potential harm and interacting with customers. As a result, Betfair was placed into special measures and agreed to make a number of urgent improvements to its processes.

27 The importance of interacting with customers (gamblingcommission.gov.uk) 28 Customer interaction guidance - for remote gambling licensees (Formal guidance under SR Code 3.4.3) (gamblingcommission.gov.uk)

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53. A follow-up compliance assessment was conducted in May 2021. As a result of that follow-up assessment the Commission was satisfied at that time that Betfair had made sufficient progress to reduce any risks associated with the licensing objectives and were generally compliant with the LCCP, and Betfair exited the special measures process in June 2021. The improvements to its processes during the special measures process included the phasing out of customer interactions conducted via email, and replacement with live chat and phone calls to interact with those customers identified as being potentially at risk.

54. The Commission was informed of Mr Ashton’s death in July 2021, and sought further information about his gambling from Betfair in order to establish whether there were any concerns around compliance with the LCCP. That information revealed some evidence around the licensee’s approach to identifying harm. There was concern that Mr Ashton’s individual circumstances were not sufficiently considered and potential indicators of harm such as spikes in losses and some increased levels of play may not have received sufficient action. We also identified that the licensee had relied only on email interactions with the customer.

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.

56. In light of the Report and the Coroner’s findings, the Commission sought to obtain the evidence considered during the inquest including a copy of the hearing bundle which was received by the Commission on 4 September 2023. The Commission will consider that evidence with a view to identifying whether there is any new, relevant evidence which has come to light during the inquest of which the Commission was not previously aware and which gives rise to compliance concerns. If so, the Commission will consider whether it would be appropriate and proportionate to take any regulatory action.

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Concern 2: The algorithm devised by 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.

57. 'Algorithms' are the technical processes used by remote operators to implement the customer interaction requirements and additional voluntary measures to further the licensing objectives and in particular the objective to protect children and other vulnerable persons from being harmed or exploited by gambling.

58. The Commission's requirements in relation to customer interaction therefore require operators deliver certain outcomes through their processes, and in the case of requirements introduced in September 2022 (referred to above at paragraph 46) also specify a number of aspects which those processes must include. Therefore, we would expect to see those aspects delivered within an operator’s algorithm(s).

59. In assessing compliance, the Commission considers whether the licensee is meeting the requirements of the licence condition or SR Code provision, and in particular SR Code 3.4.1 (which was in place at the time of Mr Ashton's gambling) and SR Code 3.4.3 (which has since been introduced in order to be more prescriptive about aspects which must be included in customer interaction systems and processes, including the algorithms used as part of this).

60. A compliance assessment focuses on whether the suite of policies, procedures and controls implemented by a licensee (including their algorithms) has been designed to identify key areas of potential risk. The critical points of those policies, procedures and controls would then be tested to ensure that they are being followed and to ensure that there are appropriate outcomes. The assessment of those critical points is achieved by reviewing records of customer accounts and understanding whether and if so, how the behaviour of the customer triggered the licensees’ safer gambling controls.

61. At the time of the compliance assessments of Betfair in December 2020 and May 2021, the requirements within the LCCP were based on principles that a Licensee should have in place processes to identify those at risk of gambling related harm and to interact with them, that process must include the identification of risks, interaction with customers and a process of

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evaluation (see paragraph 43). As stated above there was also guidance in place to assist Licensees with designing these controls, which operators were required to take into account (see paragraphs 44-45).

62. In the context of the compliance assessment conducted in relation to Betfair in December 2020, as explained above the Commission identified failings in the processes for identifying customers at risk of potential harm, and as a result of the special measures process, Betfair implemented improvements to its processes, including implementation of new safer gambling controls:
• Phased out email safer gambling interventions, replaced by phone calls and live chat.
• Updated behavioural triggers in relation to account profit and loss, deposit increases, deposit value, stakes increase, stakes value and time spent on-site.
• Daily Deposit Limit reduction to £5k for over 25’s and £1k for under 25’s.
• £100 deposit limit for customers pending a safer gambling interaction.

63. The results of our follow-up assessment in May 2021 before Betfair exited special measures in June 2021 in relation to Safer Gambling controls were that customer outcomes were improved in terms of:
• An earlier point, financially, for customer intervention which reduced customer’s exposure to losses,
• Depth and analysis of Enhanced Due Diligence for higher risk customers,
• Appropriate placing of account restrictions where necessary,
• Safer Gambling interactions, monitoring and decision-making processes.

64. In order to strengthen the requirements on licensees in relation to identifying customers at risk of harm, the Commission has introduced additional requirements directed at this issue and is consulting on further changes to contribute to improved and more effective customer interaction processes, which includes algorithms.

65. As set out above at paragraph 46, the majority of SR Code 3.4.3 was introduced in September 2022. This sets out requirements which relate to algorithms as it provides enhanced new requirements for identifying harm and taking proportionate action to the risk of harm. We will assess whether the effectiveness of identification and the effectiveness of actions taken to reduce harm improve through our compliance activity with operators.

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66. To support the strengthened requirements, we published associated guidance in August 202329, which will come into effect on 31 October 2023. The guidance repeats the individual requirements in LCCP and for each one:
• Explains the aim of each individual requirement, so that gambling operators can develop their systems to address that aim.
• Provides formal guidance which gambling operators must take into account and be able to demonstrate how they have done so.
• Supplies some additional information for further context which gambling operators are not required to take into account.

67. The guidance is intended to support operators in spotting signs of harm and taking early action. The new guidance includes consideration of individual indicators of harm that are absolute for all customers (such as frequent changes in payment methods, use or lack of use of gambling management tools), and those which are indicators of harm in the context of the customer's gambling (such as unusual patterns of gambling spend, and chasing losses). In relation to consumer vulnerability, it sets out some example scenarios of how a licensee may become aware of a vulnerability and the actions that they should take as a result. For example, if a customer mentions their ill-health during a conversation with customer service, or discusses a recent bereavement and the impact that this is having on their gambling, example actions available to the licensee could be to review the account for other indicators of harm and to ensure appropriate gambling management tools are selected by the customer or on behalf of the customer. The guidance specifically references when the customer is at risk of suicide and says that the licensee should have processes in place for identifying and escalating the risk of suicide, including where necessary referral to emergency services. It also signposts licensees to refer to the Samaritan’s guidance for gambling operators about urgent action and support for customers at risk of suicide30.

68. Further, on 26 July 2023 we published a consultation31 on financial risk and vulnerability which proposed new obligations on operators to conduct risk based and proportionate checks to understand if unusually high losses are likely to be harmful in the context of a customer’s financial circumstances, in the form of frictionless financial vulnerability checks and financial risk assessments. These measures, if introduced following consultation, would be added to

29 Customer interaction guidance - for remote gambling licensees (Formal guidance under SR Code 3.4.3) (gamblingcommission.gov.uk) 30 Samaritans - Industry guidelines for reducing the risk of gambling related suicide 31 Summer 2023 consultation on proposed changes to Licence Conditions and Codes of Practice (LCCP), Remote Gambling and Software Technical Standards (RTS), and arrangements for Regulatory Panels - The Gambling Commission - Citizen Space. The closing date for this consultation is 18 October 2023.

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the suite of customer interaction requirements and set a consistent point at which operators must understand more about customers financial risk.

69. The Commission hopes that the above information will assure the Coroner that, as part of its ongoing work to improve player protection, the Commission is implementing and promoting initiatives which should have the effect of improving customer interaction processes, including the algorithms used by the gambling industry and therefore reducing the risk of harm to consumers.

Concern 3: As was apparent through the evidence of a senior employee witness during the court 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 changing practices and patterns are likely to become problem gamblers.

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.

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…”

72. The Commission will always look to improve the requirements in the LCCP based on evidence from our own experience of regulating the industry and new research. We also publish guidance to support operators which is updated over time to reflect good practice. But better outcomes for consumers will always be achieved if operators genuinely consider what they can do to be more effective in meeting the Licensing Objectives rather than just meeting the minimum requirements as set out in LCCP.

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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.

Conclusion
74. The Commission hopes that the matters set out above address the concerns raised in the Report. If, however, further information would be of assistance we will of course endeavour to provide this, as required.