The coroner in the inquest into the death of headteacher Ruth Perry has warned there is a 鈥渞isk of future deaths if there is only lip service paid to learning from tragedies like this鈥. Heidi Connor, who concluded Perry died in January by suicide, contributed to by an Ofsted inspection, plans to issue a 鈥渞egulation 28鈥 report , and urged education secretary Gillian Keegan not to ignore its findings. She said she hoped her conclusions and report 鈥渨ill be used by the parliamentary inquiry process to review how school inspection should work going forward鈥. Keegan said government would “consider further changes to make sure we have an inspection system that supports schools and teachers, and ultimately secure Ruth鈥檚 legacy”. Perry was headteacher at Caversham Primary School in Berkshire when it was rated ‘inadequate’ by inspectors following the visit last autumn. Under regulation 28, coroners have a 鈥渄uty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths鈥. Connor said she wanted to 鈥渃onsider the statistics about responses to these reports by government departments鈥. But she told Perry鈥檚 family 鈥淩uth is not a statistic to me, so please forgive me for mentioning this point briefly鈥. She pointed to a 鈥減reventable deaths tracker鈥, created by an Oxford epidemiologist, which 鈥渟hows a tendency for some secretaries of state to ignore coroners鈥 regulation 28 reports鈥. 鈥淚 very much hope that will not be the case here.鈥 System ‘not weighed against teacher welfare’ The report will highlight seven areas of concern for Ofsted and the Department for Education, including the 鈥渋mpact on school leader welfare that this system will continue to have鈥. Connor said 鈥渁ny form of inspection or review will always be inherently stressful鈥, and that she had 鈥渢aken that into account in reaching my conclusions鈥. She added that 鈥渘obody would dispute that safeguarding is important鈥. But she warned transparency and 鈥渆ase of message to parents鈥 was 鈥渘ot currently weighed against teacher welfare. The benefits are focused on without taking account of the risks.鈥 She also noted an 鈥渁lmost complete absence鈥 of Ofsted training or published policies on dealing with signs of distress in school leaders during inspections. Ofsted has been repeatedly criticised for its response to Perry鈥檚 death. Last month, chief inspector Amanda Spielman claimed critics had used the tragedy 鈥渁s a pivot to try and discredit鈥 Ofsted鈥檚 work. Connor said Ofsted鈥檚 鈥渁pproach has been to make public statements in court, setting out their view on whether Ruth’s death was linked to the inspection and how it was carried out鈥. 鈥淭hey have publicly described this tragedy as a pivot, used to try and discredit what Ofsted does. This is without any attempt to analyse the evidence more carefully. There is a risk of future deaths if there is only lip service paid to learning from tragedies like this.鈥 Keegan will consider ‘further changes’ Keegan said Ofsted was 鈥渇undamental to making sure children are safe and receive the education they deserve鈥. 鈥淭ogether we will look closely at the coroner鈥檚 recommendations to consider further changes to make sure we have an inspection system that supports schools and teachers, and ultimately secure Ruth鈥檚 legacy.鈥 She added that 鈥渕y heart goes out to Ruth鈥檚 family, friends and the school community. Her death was a tragedy that not only shocked the local community but also the wider sector and beyond.鈥 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.