This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
The family requested me to refer to the deceased as Ruth. I will reflect that in this report. I conducted an inquest into the death of Ruth Carla Perry which concluded on 7th of December 2023. I recorded a narrative conclusion as follows:
Suicide, contributed to by an Ofsted inspection carried out in November 2022.
Circumstances of the death
This was the first Ofsted inspection that Caversham Primary School (‘CPS’) had had for 13 years. There was previously a policy which meant that schools which had been rated outstanding were not inspected in line with usual timescales. There was a policy change in 2021, and CPS was therefore due an inspection. This was the reason for the inspection in November 2022.
CPS underwent an Ofsted inspection on the 15th and 16th of November 2022, after receiving a phone call to notify them of this at 1pm on 14th November 2022. Ruth’s mental health deteriorated significantly during and after the inspection. She displayed suicidal ideation and planning a few days after the inspection. She sought mental health support, but felt unable to discuss the likely outcome of the inspection in any detail. Ruth had no relevant past mental health history. The records and evidence set out very clearly what the cause of her mental health deterioration was. She took her own life on 8th January 2023.
Other findings which I made in this case included:
1. I referred in questioning to hypothetical schools A and B. Hypothetical school A is good in all areas, but there are safeguarding concerns which can be remedied quickly. Hypothetical school B is dreadful in all respects. The system as it currently stands will mean that these 2 hypothetical schools will receive the same overall label of ‘inadequate’. For maintained schools, both would face possible academisation and job losses. 2. The lead inspector told the chair of governors that CPS had a robust safeguarding culture and that all children felt safe. We had different estimates for how long the inspection team believed the safeguarding issues identified would take to remedy. The longest of these was 30 working days. 3. Parts of the Ofsted inspection were conducted in a manner which lacked fairness, respect and sensitivity (these are the terms used in Ofsted’s Code of Conduct). This likely had an effect on Ruth’s ability to deal fully with the inspection process. It is very important to stress here that, although I necessarily had to consider the conduct of the inspectors in this matter, the focus should not be on any individual inspector, but more on the system, policies and training. 4. There is very little training by Ofsted, and no written policy, regarding management of school leader anxiety during inspections. 5. The suggestion that an inspection could be paused for reason of school leader distress was not part of Ofsted’s policy or training. 6. Ofsted’s confidentiality requirements (between inspection and final publication of the report) was a significant issue for Ruth. 7. Ruth’s employer, Reading Borough Council, clearly felt that Ofsted’s decision was wrong and unfair, but did not provide any comment on the draft report, despite asking for the opportunity to do so. 8. The legal test I have to apply is whether I consider it is likely that the Ofsted inspection contributed more than minimally to Ruth’s mental health deterioration and death. I found that it did contribute. 9. An unfavourable inspection outcome in itself would be distressing to a headteacher. However, whilst the outcome of the inspection was a part of Ruth’s distress, it was not the only cause. I remain concerned about: a. The conduct of the inspection itself. b. The current Ofsted system which allows for the single word judgement of ‘inadequate’ to be applied equally to a school rated otherwise good, but with issues that could be remedied by the time the report was published, as to a school which is dreadful in all respects. c. The confidentiality requirement at the time. d. The length of time between the inspection and final report, thus lengthening the period of the confidentiality requirement.
Coroner’s concerns
In relation to Ofsted and/or the Department for Education 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. 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. 3. Absence of a clear path to raise concerns during an inspection if these cannot be resolved directly with the lead inspector. 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. 5. Timescales for report publication. 6. No learning review of these matters was conducted by Ofsted. There is no policy requiring this to be done. 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.
Reading Borough Council 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. 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. 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.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised12
Failure to formalise post-inspection confidentiality arrangements in written policy
Lack of training or policy for recognising and responding to school leader distress during inspections
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.19
Action
Deliver mandatory mental-health awareness training to inspectors before they lead inspections, completing workforce rollout by March 2024.
Stated byOfstedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Publish and implement a policy allowing inspections to pause when serious issues require substantial action.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Update policies and documentation to permit leaders to share provisional inspection outcomes with personal, medical and professional support networks.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Appoint an independent expert to lead and publish recommendations from a learning review of the response to Ruth Perry’s death.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Clarify through handbooks, guidance, conduct codes, complaints procedures and engagement how providers can raise concerns about inspector behaviour.
Stated byOfstedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Develop and maintain clear policies and training for recognising and responding to distress during inspections.
Stated byOfstedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Review how safeguarding fits within education-framework judgements, including whether it should become a standalone judgement.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Share information about available headteacher wellbeing support through inspector training, provider documents and other communication channels.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Update inspection handbooks and practice to clarify leaders’ attendance and accompaniment at inspection team meetings.
Stated byOfstedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Establish and publish a long-term inspector development programme supporting leaders’ mental health and wellbeing.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Depersonalise inspection-report language and identify all persons responsible for a school in contextual information.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Define when future learning reviews will be commissioned, who will conduct them, how they will operate, and how lessons will be disseminated.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Operate a national helpline providing escalation to senior Ofsted staff for inspection concerns, including requests to pause inspections.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Write to all Responsible Bodies, attach the Department’s and Ofsted’s responses, and set out system responsibilities and the Department’s support offer.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Ensure Regions Group officials know about expanded wellbeing support and proactively share it with Responsible Bodies.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Fund and expand professional supervision and counselling support for school and college leaders through Education Support.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Procure a new three-year professional supervision and counselling support package for school and college leaders from April 2024.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Establish and formalize a proactive Ofsted inspection challenge and staff-stress mitigation approach, including evidence-based challenge, risk identification and inspection feedback support.
Stated byReading Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
Action
Deliver the endorsed headteacher wellbeing entitlement and support package, including coaching, mentoring or executive support alongside existing wellbeing services.
Stated byReading Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4
Position
The Department for Education owns the support available to headteachers; Ofsted’s role is to promote awareness and uptake during inspections.
Stated byOfstedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Primary responsibility for supporting school leaders rests with their employers: local authorities, academy trusts, or governing boards.
Stated byDepartment for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Ofsted leads the response to inspection concerns outside the Department’s direct responsibilities, with the Department engaging on Ofsted’s changes.
Stated byDepartment for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Final approval of HR policies on when independent learning reviews may be appropriate rests with the Council’s Personnel Committee.
Stated byReading Borough CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.34
1
Publish explanatory safeguarding communications, including blogs and webinars, to clarify inspection changes and expectations.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
2
Implement revised complaints and post-inspection processes, including direct escalation to the Independent Complaints Adjudication Service.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
3
Examine whether schools with ineffective safeguarding but otherwise good performance should receive more time to improve before reporting.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
4
Operate a national safeguarding duty desk and require inspectors to seek its support on potentially ineffective safeguarding judgements.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
5
Consult on major inspection changes and implement agreed changes during the 2024/25 academic year.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
6
Improve communication to regulated sectors about safeguarding requirements and expectations.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
7
Consult on how to explain delays when complex inspection reports take longer than usual to publish.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
8
Create an expert reference group to challenge inspector training and wellbeing integration across the education inspection framework.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
9
Conduct the cross-sector Big Listen with independent expertise and publish its details, findings and resulting proposals.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
10
Allow schools to remedy minor administrative safeguarding issues during inspections before judgement.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
11
Work with representative organisations to clarify responsibilities and processes for raising and responding to leaders’ welfare concerns during inspections.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
12
Review quality-assurance processes to identify changes that could shorten the interval between inspection and report publication.
Stated byOfstedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
13
Operate a rapid reinspection policy for otherwise good schools with safeguarding issues, enabling correction and potential grade improvement within three months.
Stated byOfstedStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
14
Brief inspectors and use sector communications to publicise leaders’ ability to share provisional outcomes and draft reports with appropriate supporters.
Stated byOfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
15
Review intervention communications from Regions Group to make them more sensitive and acknowledge pressures on recipients.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
16
Create and promote the Education Staff Wellbeing Charter as a shared commitment to staff wellbeing.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
17
Monitor and continuously review the impact of the training and communications approach.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
18
Launch a call for evidence to identify where safeguarding guidance may need further changes.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
19
Continue promoting wellbeing support through Departmental networks and sector-led communication channels.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
20
Roll out difficult-conversation and distress-response training to relevant Education and Skills Funding Agency officials.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
21
Make planned technical safeguarding-guidance clarifications in September 2024 and fundamental changes in 2025.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
22
Publish resources addressing teacher workload, staff wellbeing and flexible working practices.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
23
Undertake further work on the tone and style of communications concerning legal matters, including termination warning notices.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
24
Continue exploring refinements to the regulatory approach to provide greater clarity for headteachers.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
25
Deliver training to Departmental Regions Group officials on managing difficult conversations and responding to signs of distress.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
26
Redouble efforts to minimise the information burden placed on school leaders during intervention communications.
Stated byDepartment for EducationStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
27
Review the regulatory approach to structural intervention for schools judged inadequate solely on safeguarding.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
28
Ask Responsible Bodies to ensure appropriate support is in place after an adverse inspection judgement.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
29
Review engagement and communication with schools facing potential or actual intervention to ensure greater sensitivity to school leaders’ welfare.
Stated byDepartment for EducationStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
30
Work with Ofsted through the Big Listen to examine options for further safeguarding inspection reform.
Stated byDepartment for EducationStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
31
Conduct the commissioned independent learning review, including finalizing its terms of reference and completing the review.
Stated byReading Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
32
Develop and seek approval for HR policy provisions specifying when an independent learning review should be considered, following union engagement.
Stated byReading Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
33
Implement the Reading Borough-wide Parent Carer and Community Acceptable Behaviour Policy to support prevention of abuse to staff.
Stated byReading Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
34
Repeat the headteacher wellbeing and mental health survey annually and use its findings to update the wellbeing entitlement and support package.
Stated byReading Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
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Information checked against the published report and official responses