A coroner has described as “woefully inadequate” the information and treatment available for a 24-year-old problem gambler who took his own life in Vietnam. David Urpeth, the Sheffield coroner, on Friday delivered a narrative conclusion into the inquest of Jack Ritchie, a gambling addict who was teaching English in Hanoi. His parents, Charles and Liz Ritchie, had tenaciously fought for an inquest that not only examined their son’s death but also state regulation of the gambling industry. The coroner did not rule that any arm of the state had directly breached any duty to protect Ritchie’s life. But Urpeth said “warnings, information and treatment” for problem gamblers at the time of Ritchie’s death were “woefully inadequate and failed to meet Jack’s needs”. The situation had improved but there was still “significantly more” that needed to be done. He said he would write to government departments and gambling agencies with warnings about how future deaths could be prevented. He highlighted the need for more training for GPs about gambling disorders. Afterwards, Liz Ritchie told the Guardian it was “an extraordinary, seismic ruling”. She described the future death notices as “really clear instructions to government to do things better”. “[The coroner] found multiple state failings in regard to gambling in terms of regulation, treatment and information.” Those failings, she said, “killed Jack, they caused his death. So it was a huge ruling.” The inquest heard evidence that as many as 400 suicides a year in England could be linked directly to gambling. Charles Ritchie said the prevention of future death orders issued by the coroner were beyond what they could have hoped for. “Jack died four and a half years ago so it has been a long, long journey and to get that as a set of rulings is extraordinary.” Speaking on the steps of Sheffield town hall the couple said: “For us, this inquest has been about justice for Jack. Jack died believing he was the problem and he was harming us and his family. This is not true and the coroner found explicitly that it was not Jack’s fault. “Jack was abused by parasites who inflict life-threatening illness for profit and then blame the victims. “Jack’s inquest revealed that the link between gambling and suicide has been known for years but it’s taken the deaths of thousands to start to make proper change.” The Ritchie family argued that gambling killed their son. “It was the long-term root and the short-term trigger of Jack’s death,” they said. Urpeth suggested that was a step too far. Instead, he said it was “abundantly clear” that gambling contributed to Ritchie’s death. The coroner praised Ritchie’s parents and said they had done all they could to help their son. It is believed to be the first time article 2 of the Human Rights Act has been engaged in a case relating to suicide after gambling. That meant its scope included examining whether any arm of the state breached its duty to protect Ritchie’s right to life. Engaging article 2 had been opposed by lawyers representing the government. Ritchie’s gambling problem began when he was a sixth-former at school, betting small stakes at a betting shop on controversial fixed-odds betting terminals (FOBTs). It escalated over time, with Ritchie gambling away money left to him by his grandmother, his student loan while studying history at Hull University and, while he was in Vietnam, his overdraft. Jack’s parents set up a charity, Gambling With Lives, to support affected families and raise awareness of the dangers gambling brings. The campaign says “very normal, bright, popular and happy young folk” are killing themselves and “gambling was their only problem”. Ritchie was described by his father as “big in physique and in personality … big in heart and in spirit”. Witnesses at the inquest included Jonathan Marron, a senior civil servant at the Department of Health and Social Care, who said: “I don’t think there’s any dispute that there’s an association between gambling and suicide.” As his session finished, Marron, the director general for the Office for Health Improvement and Disparities, choked back tears as he acknowledged the trauma Jack’s parents had been through. He was the father of a teenage daughter, he said. “It’s clear that the work you have done has had a significant role in changing the focus of this issue.”