Families of gambling addicts who took their own lives have told of being let down by the coroner service, which they say failed to properly investigate the role of betting firms, a new report has revealed.

Campaign groups believe that gambling is a factor in hundreds of suicides each year, but in only one inquest has a gambling company been named as an “interested person”.

The families warned that the failure of the coroner service in England and Wales to highlight the role of gambling in many suicides over the years meant lessons were not being learned to prevent further deaths. They are calling for an overhaul of the system.

The new report, to be published on Monday , interviewed 14 people from nine families with experience of the coroner’s service following a gambling-related suicide. Many reported feeling excluded from the process, and an “unwillingness” in many cases for the role of gambling firms to be included in the scope of the inquest.

The report by Birkbeck, University of London and the University of Bath states: “Many felt that gambling companies, the broader gambling industry and indeed the government were not being held to account.”

Liz Ritchie, who co-founded the Gambling with Lives charity with her husband, Charles, after their son Jack took his life in 2017, said: “This is a group of families who are calling for justice. People are dying and it is not being properly established why.” She said that although many coroners try to be helpful, the coronial system can retraumatise bereaved families.

Jo Holloway, who lives near Exeter, said she found the inquest process “ghastly” after the death of her son, Daniel Clinkscales, in October 2017. She provided evidence for the inquest on how her “charismatic, very popular, very bright” son, who worked as a regional sales manager, was spending most of his earnings on gambling.

“I gave them the evidence, but the coronial system was not interested,” she said. “I thought I was the only person who had lost someone who had taken their life because of gambling. I felt an absolute compulsion to know what had happened to him.”

The family say the coroner did say gambling was a contributing factor in the death, but it was not included on the death certificate and they felt there was not a proper investigation in the circumstances leading up to the death or a proper examination of his digital devices. Holloway said the inquest only lasted about 20 minutes and she was not permitted to give a personal statement about her son. It recorded a verdict of suicide.

Judith Bruney, whose son Chris died in April 2017, said that while his inquest highlighted the role of gambling, it did not investigate how he had been targeted by betting firms. “He didn’t want to gamble, but they wouldn’t leave him alone,” said Bruney. “There was no escape for him. We found all these emails and texts to keep him gambling. None of that was taken into consideration.”

Bruney told the Gambling Commission about the documents she had uncovered, and it then investigated the death. Playtech, a parent company of a subsidiary involved in fuelling his gambling spree, agreed to pay a £3.5m fine, and additionally to hand over £5m to charities.

Gambling with Lives, founded in 2018, has supported families bereaved by gambling-related suicide, with some attending inquests with legal representation. The charity calls for wider access to state-funded legal representation.

In the inquest of Luke Ashton, who killed himself in April 2021, the gambling operator Betfair, owned by Flutter UK and Ireland, was named as an “interested person”, which is believed to be the first time this has happened at an inquest. The coroner found “gambling disorder” was a contributory cause of death. A prevention of future deaths report issued by the coroner reported that, despite intensive gambling activity in the weeks leading up to his death, Ashton had been assessed as “low risk” by Betfair.

Flutter said after the inquest that it was a tragic case and it had made “significant changes” to its controls, holding itself to the “absolute highest standards” in the industry. Ashton’s widow, Annie, from Leicester, who was represented by legal firm Leigh Day at the inquest in June 2023, said other inquests had failed to properly examine the role of gambling firms. “There is a failure in the coroner system,” she said. “It’s outdated, and there needs to be reform.”

The new report on gambling-related suicides, which has been supported by Gambling with Lives, is part of a wider project, Voicing Loss, on the experiences of bereaved people in coroners’ investigations and inquests. The project found there was a “marked lack of clarity” around the coroner’s role, and that the bereaved too often found the system impersonal and uncaring.

Jessica Jacobson, professor of criminal justice at Birkbeck and one of the authors of the report, said there was a “profound mismatch” between what the bereaved in gambling-related suicides expected from coroners and what they experienced: “Many felt there were missed opportunities for learning that could help prevent future deaths.”

A spokesperson for the Betting and Gaming Council (BGC), said: “BGC members voluntarily contributed over £170m over the last four years to tackle problem gambling and gambling-related harm, including £50m in 2024. Each month. around 22.5 million people in Britain enjoy a bet, and the overwhelming majority do so safely and responsibly.”

The Judicial Office said the chief coroner did not provide comment on individual research publications.

In the UK and Ireland, Samaritans can be contacted on freephone 116123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counsellor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org