12 Dec 2023 Ruth Carla Perry · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 12 Failure to formalise post-inspection confidentiality arrangements in written policy View source Lack of training or policy for recognising and responding to school leader distress during inspections View source Failure of overall inspection labels to distinguish materially different school performance View source Lack of clarity about the form of expanded school leader wellbeing support View source Lack of policy for pausing inspections because of school leader distress View source Failure to conduct or require learning reviews of inspection-related concerns View source Failure to weigh school leader welfare in inspection communications 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 communicating available mental health support options View source Failure to conduct or require internal reviews of inspection-related matters View source Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Deliver mandatory mental-health awareness training to inspectors before they lead inspections, completing workforce rollout by March 2024.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023. View source
Action
Publish and implement a policy allowing inspections to pause when serious issues require substantial action.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2023. View source
Action
Update policies and documentation to permit leaders to share provisional inspection outcomes with personal, medical and professional support networks.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2023. View source
Action
Appoint an independent expert to lead and publish recommendations from a learning review of the response to Ruth Perry’s death.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2023. View source
Action
Clarify through handbooks, guidance, conduct codes, complaints procedures and engagement how providers can raise concerns about inspector behaviour.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023. View source
Action
Develop and maintain clear policies and training for recognising and responding to distress during inspections.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023. View source
Action
Review how safeguarding fits within education-framework judgements, including whether it should become a standalone judgement.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2023. View source
Action
Share information about available headteacher wellbeing support through inspector training, provider documents and other communication channels.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2023. View source
Action
Update inspection handbooks and practice to clarify leaders’ attendance and accompaniment at inspection team meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023. View source
Action
Establish and publish a long-term inspector development programme supporting leaders’ mental health and wellbeing.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2023. View source
Action
Depersonalise inspection-report language and identify all persons responsible for a school in contextual information.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2023. View source
Action
Define when future learning reviews will be commissioned, who will conduct them, how they will operate, and how lessons will be disseminated.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2023. View source
Action
Operate a national helpline providing escalation to senior Ofsted staff for inspection concerns, including requests to pause inspections.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2023. View source See 10 more actions
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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.
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. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise post-inspection confidentiality arrangements in written policy
Wider context from the report “4. The confidentiality requirement after an inspection. Some changes have been made already, but this is not yet written into policy. Given how long this policy has been in place, school leaders may fear discussing outcomes with colleagues outside of the school, and mental health professionals, unless this is expressly dealt with in written policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure of overall inspection labels to distinguish materially different school performance
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the form of expanded school leader wellbeing support
Wider context from the report “7. In an Ofsted publication dated 12th June 2023, the Secretary of State for Education was quoted as follows: “We must ensure our school leaders have the support they need, which is why today we are significantly expanding our wellbeing support. This expansion will help make sure headteachers have access to support whenever they need it”. The Ofsted witness was not able to clarify what form this additional support has taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require learning reviews of inspection-related concerns
Wider context from the report “6. No learning review of these matters was conducted by Ofsted. There is no policy requiring this to be done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to weigh school leader welfare in inspection communications
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Lack of written policy or guidance for communicating available mental health support options
Wider context from the report “3. We heard in evidence that school leaders have received correspondence from Reading Borough Council about what mental health support options are available. I am concerned to know whether there is now written policy or guidance about communicating this, so that this continues to happen in future years .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require internal reviews of inspection-related matters
Wider context from the report “2. Reading Borough Council also did not carry out any form of internal review . I was not made aware of any policy setting out when such an internal review should take place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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.
” 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 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
×
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 policies and documentation to permit leaders to share provisional inspection outcomes with personal, medical and professional support networks.
Verbatim wording from the response “We have now updated our handbooks to make it clear that leaders can share the provisional inspection outcome and findings with whoever they deem appropriate. Leaders can share their provisional inspection outcomes with colleagues, family, medical advisers and their wider support group as they see fit.” Source location Response from Ofsted
Open published response
×
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 Appoint an independent expert to lead and publish recommendations from a learning review of the response to Ruth Perry’s death.
Verbatim wording from the response “We will appoint an independent expert to lead a learning review of Ofsted’s response to the tragic death of Ruth Perry. We will respond to the recommendations of this review as part of our response to the Big Listen.” 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
×
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
×
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 Review how safeguarding fits within education-framework judgements, including whether it should become a standalone judgement.
Verbatim wording from the response “2. We know we need to go further to continue to improve our processes and to rebuild the confidence of the sector in our work. Between January and March 2024, we will conduct a formal internal review of where aspects of safeguarding fit within the individual judgements of the education inspection framework, subject to challenge from an expert group. We will explore having safeguarding as a standalone judgement, decoupled from the leadership and management grade. We intend to complete this internal review in time to consult on options through the Big Listen, with the response to the Big Listen setting out our agreed approach to reform.” Source location Response from Ofsted
Open published response
×
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 Share information about available headteacher wellbeing support through inspector training, provider documents and other communication channels.
Verbatim wording from the response “We recognise that the DfE has ownership of the support available to headteachers, but we do believe that our inspectorate can play a positive role in ensuring support is known about and taken up when necessary. We have engaged closely with the DfE on this and recognise that inspectors should be conversant with this support and ready to remind leaders that it is available. Through our ongoing inspector training, we will reinforce the expectation that they share this information with leaders at the beginning of an inspection. We will make sure that this information is contained within documents we share with providers on inspection. We will also use our other existing channels of communication to share information about the support available to leaders, which will not only help them but also increase their capacity to support the children in their care.” Source location Response from Ofsted
Open published response
×
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
×
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 Depersonalise inspection-report language and identify all persons responsible for a school in contextual information.
Verbatim wording from the response “3. No headteacher should feel that the responsibility of an inspection and its outcome falls solely on their shoulders. In June 2023, we announced that we would look at depersonalising language used in inspection reports, the public-facing record of the inspection, so that we refer by default to ‘the school’ rather than to individuals. We also amended the contextual information within inspection reports to refer to all those with responsibility for a school. We implemented this change in September 2023.” Source location Response from Ofsted
Open published response
×
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 Define when future learning reviews will be commissioned, who will conduct them, how they will operate, and how lessons will be disseminated.
Verbatim wording from the response “At the same time, we will define clearly the circumstances in which a learning review will be commissioned in future and the procedures to be followed.” Source location Response from Ofsted
Open published response
×
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
×
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 The Department for Education owns the support available to headteachers; Ofsted’s role is to promote awareness and uptake during inspections.
Verbatim wording from the response “We recognise that the DfE has ownership of the support available to headteachers, but we do believe that our inspectorate can play a positive role in ensuring support is known about and taken up when necessary. We have engaged closely with the DfE on this and recognise that inspectors should be conversant with this support and ready to remind leaders that it is available. Through our ongoing inspector training, we will reinforce the expectation that they share this information with leaders at the beginning of an inspection. We will make sure that this information is contained within documents we share with providers on inspection. We will also use our other existing channels of communication to share information about the support available to leaders, which will not only help them but also increase their capacity to support the children in their care.” Source location Response from Ofsted
Open published response
Concerns raised 10 Lack of critical appraisal of inspections View source Deficient preplanning of monitoring visits 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 Lack of documented determination of whether a monitoring or inspection visit was required following the death of a looked after child View source Failure to clarify matters of concern with absent home managers and Responsible Individuals View source Lack of guidance for senior managers on exceptional circumstances for report publication View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Deficient preplanning of monitoring visits
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Lack of documented determination of whether a monitoring or inspection visit was required following the death of a looked after child
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify matters of concern with absent home managers and Responsible Individuals
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for senior managers on exceptional circumstances for report publication
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
” Open source report
22 Nov 2017 Ann Maguire · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Weapons such as knives being brought into schools View source Widespread variation in schools’ perception and management of weapon-related risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Maguire · 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
Ann Maguire was stabbed by a 15-year-old pupil while teaching Spanish at Corpus Christi Catholic School in Leeds. She sustained seven stab wounds and died within two hours at Leeds General Infirmary. The report raised concerns about variation in how schools perceive and manage the risks associated with weapons, and asked OFSTED to give greater prominence to school safety and the prevention of violent attacks.
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. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Weapons such as knives being brought into schools
Wider context from the report “The need to prevent weapons such as knives being brought into schools in the UK is axiomatic. How schools perceive the risks associated with weapons and manage them, appears to be the subject of widespread variation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Widespread variation in schools’ perception and management of weapon-related risks
Wider context from the report “The need to prevent weapons such as knives being brought into schools in the UK is axiomatic. How schools perceive the risks associated with weapons and manage them, appears to be the subject of widespread variation.
” Open source report
×
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 Review the inspection framework to consider giving greater focus to protecting pupils and staff from violent attack.
Verbatim wording from the response “We agree with the Coroner’s concern regarding the need to prevent weapons being brought into schools. In relation to the specific recommendations for Ofsted, the need for inspectors to report on the arrangements in schools for protecting pupils is already a mandatory part of our inspection process. Our current inspection framework for education inspections is undergoing a review with a view to having a revised framework in place for September 2019. We will, as part of that review, consider whether it is possible to give more focus to the specific matter of protecting pupils and staff from the risk of violent attack.” Source location Ann-Maguire-Response
Open published response
×
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 Take the coroner’s concerns into account in future safeguarding reviews of the school inspection process.
Verbatim wording from the response “Ofsted’s cross remit Safeguarding Group has a responsibility to keep under review the effectiveness of our school inspection process in so far as it relates to safeguarding. The chair of this group has been made aware of the coroner’s concerns and these will be taken into account in future reviews.” Source location Ann-Maguire-Response
Open published response
×
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 Mandatory inspection reporting already covers schools’ arrangements for protecting pupils, limiting the need for separate reporting requirements.
Verbatim wording from the response “We agree with the Coroner’s concern regarding the need to prevent weapons being brought into schools. In relation to the specific recommendations for Ofsted, the need for inspectors to report on the arrangements in schools for protecting pupils is already a mandatory part of our inspection process. Our current inspection framework for education inspections is undergoing a review with a view to having a revised framework in place for September 2019. We will, as part of that review, consider whether it is possible to give more focus to the specific matter of protecting pupils and staff from the risk of violent attack.” Source location Ann-Maguire-Response
Open published response
×
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 The Department for Education is the appropriate body to consider publishing a national prohibited-items list.
Verbatim wording from the response “In terms of the second part of the recommendation about Ofsted publishing a list of prohibited items, to do this would be going beyond Ofsted’s responsibility as inspectorate. Such matters are relevant to the Department for Education (DfE), as the lead government policy department with responsibility for schools. I note that a” Source location Ann-Maguire-Response
Open published response
×
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 Publishing a national list of prohibited items falls beyond the inspectorate’s responsibility.
Verbatim wording from the response “In terms of the second part of the recommendation about Ofsted publishing a list of prohibited items, to do this would be going beyond Ofsted’s responsibility as inspectorate. Such matters are relevant to the Department for Education (DfE), as the lead government policy department with responsibility for schools. I note that a” Source location Ann-Maguire-Response
Open published response
14 Jul 2017 Steffan Bonnot · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Failure to provide prospective carers with all relevant background information about a child View source Failure to document information disclosed to prospective carers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steffan Bonnot · 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
Steffan Bonnot, a 17-year-old in the care of Brighton and Hove Local Authority, left a group during an outing on 1 January 2016 and was later found at a footcrossing after being struck by a train. The report states that he had anxiety about moving to a new foster placement and whether the prospective foster carers had been fully informed about his background. A principal concern was the lack of formal documentation showing exactly what information had been disclosed to the prospective foster carers.
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. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prospective carers with all relevant background information about a child
Wider context from the report “1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case . This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed. It was not therefore possible to be clear what information the prospective Foster Carer had been given. As we know the failing to provide Foster Carers with all the background information was one of Steffan’s major concerns and added to his level of anxiety about his move.
2. The above concern would apply equally to any individuals entrusted with the care of a child. All relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer’s knew.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Failure to document information disclosed to prospective carers
Wider context from the report “1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case. This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed . It was not therefore possible to be clear what information the prospective Foster Carer had been given . As we know the failing to provide Foster Carers with all the background information was one of Steffan’s major concerns and added to his level of anxiety about his move.
2. The above concern would apply equally to any individuals entrusted with the care of a child. All relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer’s knew.
” Open source report
29 Sep 2014 Tiya Chetan Chauhan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of awareness of the choking risks of raw jelly cubes during play View source Absence of choking-risk warnings on packets of raw jelly View source Insufficient supervision of raw jelly play with young children View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tiya Chetan Chauhan · 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
Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.
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. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the choking risks of raw jelly cubes during play
Wider context from the report “(1) That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the especial risks of choking that a cube of raw jelly presents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-risk warnings on packets of raw jelly
Wider context from the report “(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofsted; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of raw jelly play with young children
Wider context from the report “(3) That raw jelly cubes may be used in play with young children without sufficient supervision .
” Open source report
×
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 Disseminate the inquest findings and raw-jelly activity risks to Ofsted and contracted early-years inspectors for consideration during EYFS compliance inspections.
Verbatim wording from the response “In inspecting registered early years providers, Ofsted inspects compliance with the EYFS requirements including those relating to the risk assessment of activities and supervision. Any breach of EYFS requirements arising from unsafe practices would result in appropriate regulatory action by Ofsted. We will ensure that the findings of the inquest are disseminated to Ofsted and contracted inspectors of EY provisions so that they are aware of the risks of the use of raw jelly in activities in their inspection of EYFS compliance. As was made clear at the inquest, the use of raw jelly in activities in play is not specifically precluded by the EYFS.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 Include the inquest findings and raw-jelly choking risks in the next newsletter to local authority children’s services directors, copying it to the Department for Education.
Verbatim wording from the response “Ofsted will be including details of the inquest, including its findings of the risks associated with the use of raw jelly during play by children, in its next regular newsletter to all Directors of Children’s Services (DCSs) in local authorities in England. As we explained in our evidence, local authorities, not Ofsted, have the statutory duty to provide information, advice and guidance to childcare providers. It is therefore for local authorities to advise individual providers of the risks posed by raw jelly, but Ofsted can support this by bringing to their attention the matters highlighted in the inquest. The aim of this will be to highlight the risks of raw jelly play by children in childcare and school settings. It will be for the DCS’s to decide how best to disseminate this information further to these settings.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 The Food Standards Agency will respond about possible further action on warnings for raw jelly packaging.
Verbatim wording from the response “The inclusion of warnings on the packaging of food items and products is not a matter for Ofsted. We have discussed this concern with the FSA and have agreed that they will respond to you on the possibility for further action.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 Warnings on food-product packaging are outside Ofsted’s remit.
Verbatim wording from the response “The inclusion of warnings on the packaging of food items and products is not a matter for Ofsted. We have discussed this concern with the FSA and have agreed that they will respond to you on the possibility for further action.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 Local authorities, not Ofsted, are responsible for advising childcare providers about raw jelly risks and deciding how to disseminate that information.
Verbatim wording from the response “Ofsted will be including details of the inquest, including its findings of the risks associated with the use of raw jelly during play by children, in its next regular newsletter to all Directors of Children’s Services (DCSs) in local authorities in England. As we explained in our evidence, local authorities, not Ofsted, have the statutory duty to provide information, advice and guidance to childcare providers. It is therefore for local authorities to advise individual providers of the risks posed by raw jelly, but Ofsted can support this by bringing to their attention the matters highlighted in the inquest. The aim of this will be to highlight the risks of raw jelly play by children in childcare and school settings. It will be for the DCS’s to decide how best to disseminate this information further to these settings.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 Writing directly to all registered childcare providers about raw jelly risks and advising on EYFS delivery falls outside Ofsted’s statutory remit.
Verbatim wording from the response “Ofsted has given careful consideration to whether it should write out to all registered childcare providers but has concluded that this would be outside Ofsted’s statutory remit. As mentioned above, Ofsted cannot advise settings on how to deliver the requirements of the Early Years Foundation Stage (EYFS) since legislative provisions clearly place the obligation for advice and training of childcare settings on Local Authorities.” Source location 2014-0575-Response-by-Ofsted
Open published response
×
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 inspectors cannot advise or require providers to stop using raw jelly because the EYFS does not specifically prohibit it.
Verbatim wording from the response “In inspecting registered early years providers, Ofsted inspects compliance with the EYFS requirements including those relating to the risk assessment of activities and supervision. Any breach of EYFS requirements arising from unsafe practices would result in appropriate regulatory action by Ofsted. We will ensure that the findings of the inquest are disseminated to Ofsted and contracted inspectors of EY provisions so that they are aware of the risks of the use of raw jelly in activities in their inspection of EYFS compliance. As was made clear at the inquest, the use of raw jelly in activities in play is not specifically precluded by the EYFS.” Source location 2014-0575-Response-by-Ofsted
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations