The MATIERS OF CONCERN are as follows. - During the inquest, evidence showed:­
- That the system of regulation in force at the time of his death did not stop Jack gambling at a point when he was obviously addicted to gambling
- The warnings Jack received were insufficient to prevent him gambling

- The information available to Jack was insufficient to prevent him gambling or to inform him of the help / treatments available
- The treatment available and received by Jack was insufficient to cure his addiction ­ this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
- Jack didn't understand that being addicted to gambling wasn't his fault. That lack of understanding lead to feelings of shame and hopelessness which is turn, contributed to him feeling suicidal
- That in the time since Jack's death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
- The evidence was that young people were the most at risk from the harms of gambling yet there was and still appears to be, very little education for school children on the subject. As I said in open court and repeat here, I stress I am not, and would not, attempt to tell government upon what and how they should act or indeed legislate. I issue this preventing future death report in the hope that Government finds the concerns raised informative and of assistance, especially at a time they are considering the whole issue of gambling and its regulation. Indeed, I recall the Director General of Dept of Health and Social Care who gave evidence at the inquest saying that Government was looking to this inquest to learn. I therefore hope this preventing future death report will assist in this regard. I leave the government, as they see fit, to cascade this report to all appropriate government departments, as well as any other organisations, professional bodies or charities working within the arena of problem gambling. I do this as the government are best placed to control or oversee legislation, regulation, education, treatment and support, and to promote any actions around the issue of problem gambling designed to prevent future deaths.