Last month, Heidi Connor, Berkshire鈥檚 senior coroner who presided over the inquest into Ruth Perry鈥檚 death, sent a Regulation 28 Report To Prevent Future Deaths to His Majesty鈥檚 chief inspector of schools (HMCI), the secretary of state for education and the chief executive of Reading borough council. 鈥淚n my opinion,鈥� Ms Connor told all three, 鈥渁ction should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.鈥� Those named have until 7 February to respond in writing, and while Ofsted will not be swept away as a result we should expect significant changes to make the inspection process less stressful. Ms Connor insists the responses: 鈥渕ust contain details of action taken or proposed to be taken, setting out the timetable for action鈥�. A quarter of a century ago, I researched toxic stress and its effects on teachers and schools for my book Breakdown: The Facts About Teacher Stress. What I discovered then is backed up by Ms Connor鈥檚 findings set out in her report, as well as by 218 pieces of published by the education select committee鈥檚 . These submissions, from organisations, parents, pupils, governors, academics, as well as serving and former teachers and school leaders make it very clear how and why Ofsted causes hugely toxic stress. So what should be in the three written responses? How can inspections be made less stressful so that the risk of future tragedies is minimised? First, the secretary of state, Gillian Keegan needs to abolish one-word judgements, stop the practice of sacking headteachers for a single Ofsted failure and institute a better, more effective way of monitoring safeguarding, taking it away from the inspection of teaching and learning. Incoming HMCI, Sir Martyn Oliver has his first priority will be his written response to the inquest findings. He should commit to ensuring all inspections are fair and transparent. Ofsted employees must behave at all times with courtesy, respect and honesty, and any found to have lied or manufactured evidence should be sacked. Planning for fundamental reform should also start now Timings also need shaking up: the interminable waiting leading up to an inspection and afterwards for the publication of the report heap needless stress on school leaders. In addition, we need a fair, independent and effective appeals process. Most important of all is that inconsistency and subjectivity must end. A whole industry has flourished on trying to second guess 鈥渨hat Ofsted wants鈥�: 鈥榤ocksteds鈥� rack up the pressure on schools; senior leaders become inspectors for the inside knowledge; goalposts shift with frightening frequency. All too often, headteachers and governors quite literally do not know what they must do to be sure of achieving a good outcome, particularly those in schools serving deprived areas. This is a huge source of stress and it is simply not good enough. One consequence of the present inconsistency is that local authorities have 鈥榣ink inspectors鈥� who give them an inside track. The inquest heard that Reading borough council (RBC) abandoned Ruth in her hour of need. It believed the judgement on Caversham Primary was unfair, yet withdrew Ruth鈥檚 appeal against the verdict, choosing to prioritise its relationship with the lead inspector who was also its Ofsted link inspector. (It did this, let鈥檚 be fair, imagining that in this way it could better serve its other schools). RBC鈥檚 written response to the coroner should be a model for local authorities and multi-academy trusts across the country. It needs to state baldly and simply that it will support its employees. If the highest stakes are removed by Gillian Keegan while Sir Martyn ensures inspections are fair, transparent and consistent, there should be no need of link inspectors. In any case, RBC (like all LAs and MATs) are providers of schools; they need to remove themselves entirely from the policing. These plans are for immediate implementation. They don鈥檛 replace proper, fundamental reform of school inspection, planning for which should also start now. They are interim measures, but as first steps they signal a vital promise: never again.