There is a risk of further deaths following the suicide of head teacher Ruth Perry, “unless action is taken”, a coroner has told Ofsted and the education secretary.
Mrs Perry, 53, killed herself in January, while waiting for an Ofsted report to be published.
At her inquest, Heidi Connor ruled an Ofsted inspection had “contributed” to her death.
Ofsted previously said it was making several changes.
Ms Connor has issued a prevention-of-future-deaths notice (PFD), to prevent similar situations.
She said she was concerned by “the almost complete absence of Ofsted training” for inspectors looking for signs of distress in school leaders or for pausing an inspection.
There was also no “clear path” to raise concerns during an inspection.
Mrs Perry had been the head teacher at Caversham Primary School for 13 years and had had no relevant past mental-health history, the coroner said.
Safeguarding concerns saw the school downgraded from “outstanding” to “inadequate”, after Ofsted’s visit, in November 2022.
It has since been regraded “good”.
After the inspection, Mrs Perry had told her husband she thought she would lose her job, the judgement was “all her fault” and “Caversham house prices would go down” because of it, the inquest heard.
Mr Perry said she had not been allowed to talk about the Ofsted result with anyone and spent the next eight weeks “constantly returning obsessively to the trauma of the inspection”.
“The records and evidence set out very clearly what the cause of her mental-health deterioration was,” Ms Connor wrote in her report.
Ofsted had failed to carry out a learning review following Mrs Perry’s suicide. And although some changes had been made around confidentiality of Ofsted reports, school leaders may fear discussing outcomes of inspection with colleagues outside of the school, and mental-health professionals, unless this was expressly dealt with in written policy.
Some of her concerns were “outside the gift of Ofsted”, Ms Connor noted, writing: “That is part of the reason for including the Department for Education as a recipient of this report.”
She also highlighted Ofsted’s one-word rating system, where some safeguarding issues that could be resolved by the time the report was published could mean an otherwise good school receiving the same “inadequate” rating as one failing in all areas.
“Transparency and ease of message to parents is not currently weighed against teacher welfare,” Ms Connor said. And she was worried about the impact on school leaders’ welfare.
Reading Borough Council said it would take a proactive approach to Ofsted following Mrs Perry’s suicide. But this was not yet in written guidance, Ms Connor said, which may go some way towards reassuring school leaders their employer “has their back”.
After receiving the PFD, Ofsted, the Department for Education and Reading Borough Council have 56 days to say how they plan to mitigate the risk of future deaths.
Last week, Ofsted delayed inspections by a day and said it was developing new training for all inspectors, to include external experts, in early January.
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