12 Dec 2023 Ruth Carla Perry · Prevention of Future Deaths report Berkshire
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Concerns raised 5
Lack of training or policy for recognising and responding to school leader distress during inspections View source Lack of policy for pausing inspections because of school leader distress View source Absence of a clear escalation path for unresolved inspection concerns View source
Lack of policy on who may attend meetings with inspectors View source Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns View source See 2 more concerns
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ruth Carla Perry · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ruth Carla Perry’s mental health deteriorated significantly during and after an Ofsted inspection of Caversham Primary School in November 2022. She displayed suicidal ideation and planning a few days later, and took her own life on 8 January 2023; the inquest concluded that her suicide was contributed to by the inspection. The principal concerns included the conduct and fairness of the inspection, limited Ofsted training and policy for managing school leader distress, confidentiality requirements, report publication timescales, and aspects of the inspection system affecting school leader welfare.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of training or policy for recognising and responding to school leader distress during inspections
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” Source location Ruth Carla Perry · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of policy for pausing inspections because of school leader distress
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” Source location Ruth Carla Perry · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a clear escalation path for unresolved inspection concerns
Wider context from the report “3. Absence of a clear path to raise concerns during an inspection if these cannot be resolved directly with the lead inspector.
” Source location Ruth Carla Perry · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of policy on who may attend meetings with inspectors
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” Source location Ruth Carla Perry · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns
Wider context from the report “1. Reading Borough Council indicated an intention to adopt a much more robust and proactive approach to dealing with Ofsted, particularly where there are concerns about an inspection. This is not written policy or guidance – which may go some way towards reassuring school leaders that their employer ‘has their back’ – both now and in future years.
” Source location Ruth Carla Perry · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory mental-health awareness training to inspectors before they lead inspections, completing workforce rollout by March 2024.
Verbatim wording from the response “We set a later start date for school and further education (FE) inspections this term to enable us to provide mental health awareness training for all inspectors, in all the areas we work (inspections continued in social care and early years, where we are also the regulator). This training is not just about spotting signs of distress but also about how we work to reduce anxiety while carrying out our crucial duty. We recognise that any form of inspection is likely to be challenging, but it must be proportionate and carried out with care.” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and publish a long-term inspector development programme supporting leaders’ mental health and wellbeing.
Verbatim wording from the response “But we need to go further. We will establish a long-term development programme for inspectors that helps them to support leaders’ well-being. We will publish our development roadmap for this in spring 2024.” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and maintain clear policies and training for recognising and responding to distress during inspections.
Verbatim wording from the response “Inspectors should take steps to minimise stress and anxiety during inspection. They should be able to recognise signs of distress in those they meet and know how to respond. Ofsted will therefore immediately begin developing clear and robust policies and training to improve practice and enable inspectors to identify and respond to signs of distress in leaders and staff (2a and 2b).” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a national helpline providing escalation to senior Ofsted staff for inspection concerns, including requests to pause inspections.
Verbatim wording from the response “The Coroner is correct that there has previously been no clear, written policy for pausing inspections. Every inspector and every school leader must have clarity about when and how to pause inspections. We also want to give leaders confidence that a request for a pause will not affect adversely the judgements made about a school. In response to our consultation on complaints about inspection, we introduced a new process for pausing inspection in December 2023, using a national helpline. We have since developed and published a national policy on pausing inspections (2c).” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and implement a policy allowing inspections to pause when serious issues require substantial action.
Verbatim wording from the response “The Coroner is correct that there has previously been no clear, written policy for pausing inspections. Every inspector and every school leader must have clarity about when and how to pause inspections. We also want to give leaders confidence that a request for a pause will not affect adversely the judgements made about a school. In response to our consultation on complaints about inspection, we introduced a new process for pausing inspection in December 2023, using a national helpline. We have since developed and published a national policy on pausing inspections (2c).” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify through handbooks, guidance, conduct codes, complaints procedures and engagement how providers can raise concerns about inspector behaviour.
Verbatim wording from the response “2. We will also clarify in our handbooks, accompanying guidance, code of conduct, complaints procedures and during stakeholder engagement, how providers can raise concerns about inspectors’ behaviour, including any safeguarding concerns. We have already started this process, for example publishing an update to the education inspection handbooks, and intend to complete it by the end of March 2024.” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and formalize a proactive Ofsted inspection challenge and staff-stress mitigation approach, including evidence-based challenge, risk identification and inspection feedback support.
Verbatim wording from the response “Brighter Futures for Children Ltd (on behalf of the Council) has consulted with Head Teachers regarding a more robust and proactive approach by responding to inspections on behalf of school leaders and Governors, through the termly meeting of Reading Headteachers (Friday 12 January 2024) and via the Reading school primary and secondary phase teacher associations (week commencing 15 January).
The principle of the new approach is that Brighter Futures for Children will work with school leaders to understand any concerns regarding an inspection and offer to undertake challenge on a school’s behalf, before, during and after inspection, based on a robust evidence base. This builds on current practice which supports schools to consider” Source location Response from Reading Borough Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update inspection handbooks and practice to clarify leaders’ attendance and accompaniment at inspection team meetings.
Verbatim wording from the response “5. From December 2023, during notification calls, inspectors have been required to actively remind and encourage headteachers to have someone accompany them at end-of-day inspection team meetings. Inspectors emphasise that school leaders are invited to attend the meeting but are not required to, with no conclusions drawn if they do not wish to attend. We reiterated this in our December 2023 briefing to inspectors, helping to ensure that we see – and schools experience – consistent practice from our inspector workforce (2d).” Source location Response from Ofsted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ofsted leads the response to inspection concerns outside the Department’s direct responsibilities, with the Department engaging on Ofsted’s changes.
Verbatim wording from the response “A series of changes to the inspection arrangements were announced in June 2023. These were an important start but, as evidenced by the Report, did not go far enough. Ofsted’s response to the Report, which DfE officials and I have discussed in detail with ████████, Ofsted’s new Chief Inspector, sets out fully the changes to inspection that were made prior to the inquest, and importantly, subsequently to the inquest. These include immediate steps taken pre-Christmas and the important inspector training that has taken place at the start of January 2024.” Source location Response from Department for Education
Open published response
Concerns raised 6
Lack of critical appraisal of inspections View source Failure of inspectors to consider relevant safeguarding documentation View source Drawing unsupportable conclusions from available documentation View source
Insufficient enquiry during inspections View source Misinterpretation of available evidence during inspections View source Failure of inspectors to consider significant information indexed in the file View source See 3 more concerns
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Oliver Brassington Weston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Brassington Weston was a 17-year-old looked after child placed in a home by Stockton Borough Council. He died at Cumbria View House on the evening of 22 March 2019 following an impulsive act involving ████████. The concerns included deficiencies in the planning, conduct and review of an inspection, failure to consider relevant safeguarding and psychological information, and a lack of guidance about when inspection reports should not be published in exceptional circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of critical appraisal of inspections
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection . A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of inspectors to consider relevant safeguarding documentation
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Drawing unsupportable conclusions from available documentation
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient enquiry during inspections
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry , misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Misinterpretation of available evidence during inspections
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of inspectors to consider significant information indexed in the file
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry
(3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector
(4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published
(8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals
” Source location Oliver Brassington Weston · Prevention of Future Deaths report
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Includes failures in explicitly Ofsted inspection processes and their dedicated controls, including inspection-policy clarity, meeting participation, preparation, relevant-information review, evidence appraisal, conclusions and inspection reporting where these deficiencies affect the reliability of safety-related inspection decisions.
