Ofsted鈥檚 response to Ruth Perry鈥檚 death appeared 鈥渄efensive and complacent鈥 and the watchdog must move away 鈥渇rom the discourse that ‘inspectors are never wrong’鈥, a damning review has found. Former chief inspector Dame Christine Gilbert鈥檚 lessons learned review said the headteacher鈥檚 suicide had 鈥渟hone a light on a climate of fear and frustration around school inspection, which had been building for years鈥. This climate 鈥渉ad the consequence of weakening trust in Ofsted, which was increasingly seen by many as defensive and unwilling to respond constructively to criticism鈥. It also impacted school leaders鈥 and staff wellbeing 鈥渁nd thereby contributed to the recruitment and retention crisis evident across the sector鈥. New chief inspector Sir Martyn Oliver commissioned , which made a series of recommendations (see below). A coroner ruled in December that an Ofsted inspection at Caversham Primary School in Reading contributed to Perry鈥檚 death. ‘No attempt’ in early 2023 to contact family The review found Ofsted鈥檚 initial response to the tragedy 鈥渁ppears defensive and complacent rather than reflective and self-critical鈥. Gilbert, chief inspector between 2006 and 2011, found there was 鈥渘o attempt by Ofsted in the early months of 2023 to contact the school or Ruth Perry鈥檚 family鈥. Gilbert 鈥淭here seems to have been no understanding in Ofsted at this point that Ruth Perry鈥檚 death was directly linked to the inspection itself. This lack of understanding is disputed, particularly by Ruth Perry鈥檚 family.鈥 Ofsted鈥檚 initial approach 鈥渓ooks primarily defensive鈥, with a board member describing the inspectorate鈥檚 approach as 鈥渁ppearing to start from the premise that Ofsted had done nothing wrong and just needed to provide the evidence to demonstrate that”. Later in the year, Ofsted 鈥渞esponded swiftly鈥 to the findings of the coroner and education committee. 鈥淚f this kind of self-critical approach, with more openness to the need for self-reflection and learning, had been adopted at the beginning of 2023, this might have appeared as less of a 鈥榟andbrake turn鈥.鈥 鈥楢dmit inevitable human error鈥 Gilbert said all Ofsted staff needed to 鈥渟ee the potential鈥 of incidents that have significant consequences for stakeholders or staff. 鈥淲here appropriate, they need to be able to admit to inevitable human error when it occurs. It is important that inspectors (and all staff up to and including HMCI) are never placed beyond human fallibility, moving away from the discourse that 鈥榠nspectors are never wrong鈥.鈥 Gilbert said Ofsted鈥檚 鈥淏ig Listen鈥, which reports today, was the 鈥渇irst step on that path of significant change and it reinforces Ofsted鈥檚 commitment across all remits to serve the interests of users鈥. 鈥淗owever, the proof of Ofsted鈥檚 determination to change will be in its actions. It needs to act in response to a number of very hard messages to effect real and sustainable change, and its progress in doing so needs to be closely monitored.鈥 Gilbert鈥檚 recommendations… 1. Create 鈥榦verarching improvement plan鈥 Gilbert said Ofsted鈥檚 actions 鈥渟hould continue with a sense of urgency鈥. The changes should be 鈥渋ntegrated into a single, overarching improvement and development plan which is owned by HMCI, staff and the board鈥. This 鈥渢op-level plan and regular monitoring reports should be published for transparency on Ofsted鈥檚 website鈥. The review added that inspectors and support staff 鈥渟hould be fully engaged in the design of Ofsted鈥檚 new approach to professional learning and development鈥. Ofsted said it fully accepted these recommendations. 2. Train up Ofsted leaders in crisis communications The review found Ofsted鈥檚 initial response to the tragedy 鈥渁ppears defensive and complacent rather than reflective and self-critical鈥. The lack of awareness 鈥渟erved to make the coroner鈥檚 findings all the more shocking for Ofsted鈥. 鈥淚t increased the damage to its reputation, not only externally where stakeholders could perceive this defensiveness from media coverage, but also internally where both staff and the board could see the difference between the coroner鈥檚 judgments and what they had been told.鈥 Ofsted should organise a senior leadership development session, involving board members and the executive team, to 鈥渨ork through a range of critical and serious incident scenarios鈥. It should 鈥渋nclude input from experts on crisis communications鈥. National directors, supported by other senior leaders, should 鈥減lay a leading and authoritative role as the guardian of inspection standards and practice in any future critical or serious incident鈥. Ofsted said it fully accepted the recommendations. 3. Contract out post-inspection surveys Gilbert found an 鈥渙bvious mismatch鈥 between Ofsted鈥檚 post-inspection surveys findings and externally-commissioned research carried out for the Big Listen. Independent external reviews and evaluations should be built into Ofsted鈥檚 plans for reform. Post-inspection surveys should also be administered through a third-party independent organisation. Ofsted accepted the recommendation of independent research to evaluate reforms. But it said it needed longer to consider the 鈥渂udgetary implications鈥 of contracting out post-inspection surveys. 4. Don鈥檛 鈥榮hift the balance鈥 on safeguarding Ofsted’s safeguarding changes have been 鈥減articularly important鈥, Gilbert said. For instance, a new hub now fields calls from inspectors about safeguarding. But 鈥渟ome inspectors talked to this review about their concerns around the impact of additional scrutiny of decision making in this area鈥. Gilbert said Ofsted should 鈥渆nsure that the changed approach to safeguarding does not shift the balance to the point where it causes inspectors to avoid making the right decisions in the interest of keeping children safe鈥. Ofsted said it fully accepted the recommendation. 5. Embed external oversight in complaints Changes to complaint procedures have been 鈥渨ell received but there remains a strong feeling that there is far more to do鈥. HMIs also reported incidents of senior leaders at inspected providers using the new complaints process to 鈥渆xert pressure鈥, Gilbert said. 鈥淪ome suggested it would help if there was additional on-site quality assurance from senior inspectors when issues emerge.鈥 Ofsted should 鈥渃ontinue to improve its complaints procedure, with a focus on embedding an element of independent external oversight with the power to re-open inspection judgements鈥. Ofsted said it was setting up a 鈥渃omplaints about Ofsted鈥 hub to centralise its process. Complaints panels, which have been piloted, will become permanent. 6. Operate as a 鈥榰nified organisation鈥 This review found the learning from Perry鈥檚 death 鈥渨as determined, and in some ways constrained, by Ofsted鈥檚 organisational structure and culture鈥. Its regional structure, introduced in 2013, had 鈥渘egative consequences鈥. Regions were 鈥渄eliberately set up to be in competition with each other, particularly in Ofsted鈥檚 drive to complete the required volume of inspections鈥. Inspectors 鈥渋dentified significant differences in style and culture as well as in the operation of terms and conditions鈥. Gilbert said there 鈥渟hould be an internal drive for Ofsted to operate as a unified organisation to help ensure a more holistic approach to learning and development鈥 and 鈥渟hould also address inconsistencies in practice.鈥 Ofsted said it fully accepted the recommendation. 7. Put greater emphasis on performance management Performance management is 鈥減atchy, with staff themselves expressing concerns that poor performance was not always dealt with effectively,鈥 the report said. The review 鈥渉eard that, at times, there had been a reluctance to address conduct issues when they were raised, with people 鈥榞etting away with being unpleasant鈥.鈥 Ofsted should 鈥減lace a greater emphasis on managing and supporting the performance of inspectors so that everyone is clear about what is expected of them, how well they are doing and what support might be needed to do better鈥. Ofsted said it fully accepted the recommendation. 8. Don鈥檛 鈥榗hase鈥 inspection volume over quality Inspectors and some senior leaders raised concerns that efforts to learn from the tragedy and give inspections a 鈥渕ore human face鈥 were 鈥渦ndermined by the significant budget cuts the organisation has faced over the last decade and the pressure to complete the volume of required inspections鈥. 鈥淭he review heard the phrase 鈥榲olume trumps quality鈥 from inspectors, time and time again.鈥 Oliver Gilbert said Ofsted should 鈥渞eview its key performance indicators and the way it drives priorities鈥. The watchdog accepted that recommendation. Ofsted should also 鈥渁dvise the DfE and the new government of the dangers associated with chasing school inspection volume at the expense of inspection quality鈥. The watchdog said it did 鈥渘ot accept that we have chased inspection volumes over inspection quality鈥. 鈥淲e regret that we have been forced to de-prioritise vital system improvements in order to prioritise inspections. We agree that we have had to make difficult decisions about what to prioritise. But we have always prioritised 鈥 to the detriment of much else 鈥 the quality of inspection.鈥 9. 鈥楳ore sophisticated鈥 mental health training needed Ofsted鈥檚 work to roll out mental health training in 2024 鈥渟hould now be built on with more sophisticated training, regularly refreshed鈥. This should be 鈥渟pecifically designed to reflect the unique power dynamic of inspection, with specific models and tools to support inspectors to build appropriate relationships during inspection鈥. Ofsted said it fully accepted the recommendation. 10. Strengthen board to reduce 鈥榚ntitlement鈥 of chief inspector This review found the Ofsted board 鈥渉ad little or no involvement in determining the strategy for dealing with the crisis and communicating to the media and stakeholders鈥. The board鈥檚 role 鈥渁ppears curiously limited, apparently leaving some of Ofsted鈥檚 most critical activities outside of its control, unless HMCI chooses to let it have some control鈥. 鈥淭his degree of autonomy and entitlement for HMCI does not make for effective governance.鈥 Ofsted should review its governance framework to 鈥渟trengthen the role of the board with the aim of establishing constructive challenge to support Ofsted in its learning and reform鈥. Ofsted said it fully accepted the recommendation. 11. Consider wider accountability system, DfE told As part of its planning for a school report card, the government should 鈥渋nitiate a debate about the essential elements of the wider public accountability system, of which Ofsted is a part鈥. Ofsted said it agreed with the 鈥渟pirit鈥 of the recommendation. are available 365 days a year. You can reach them on free call number 116 123, email them at jo@samaritans.org or visit to find your nearest branch. runs a confidential helpline for education staff and teachers 鈥 call 08000 562 561.