Ofsted’s response to Ruth Perry’s death appeared “defensive and complacent” and the watchdog must move away “from the discourse that ‘inspectors are never wrong’”, a damning review has found.
Former chief inspector Dame Christine Gilbert’s (pictured) lessons learned review said the headteacher’s suicide had “shone a light on a climate of fear and frustration around inspection, which had been building for years”.
This climate “had the consequence of weakening trust in Ofsted, which was increasingly seen by many as defensive and unwilling to respond constructively to criticism”.
It also impacted leaders’ and staff wellbeing “and thereby contributed to the recruitment and retention crisis evident across the sector”.
New chief inspector Sir Martyn Oliver commissioned the review, 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’s death.
‘No attempt’ in early 2023 to contact family
The review found Ofsted’s initial response to the tragedy “appears defensive and complacent rather than reflective and self-critical”.
Gilbert, chief inspector between 2006 and 2011, found there was “no attempt by Ofsted in the early months of 2023 to contact the school or Ruth Perry’s family”.
“There seems to have been no understanding in Ofsted at this point that Ruth Perry’s death was directly linked to the inspection itself. This lack of understanding is disputed, particularly by Ruth Perry’s family.”
Ofsted’s initial approach “looks primarily defensive”, with a board member describing the inspectorate’s approach as “appearing 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 “responded swiftly” to the findings of the coroner and education committee.
“If 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 ‘handbrake turn’.”
‘Admit inevitable human error’
Gilbert said all Ofsted staff needed to “see the potential” of incidents that have significant consequences for stakeholders or staff.
“Where 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 ‘inspectors are never wrong’.”
Gilbert said Ofsted’s “Big Listen”, which reports today, was the “first step on that path of significant change and it reinforces Ofsted’s commitment across all remits to serve the interests of users”.
“However, the proof of Ofsted’s 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.”
Gilbert’s recommendations…
1. Create ‘overarching improvement plan’
Gilbert said Ofsted’s actions “should continue with a sense of urgency”.
The changes should be “integrated into a single, overarching improvement and development plan which is owned by HMCI, staff and the board”.
This “top-level plan and regular monitoring reports should be published for transparency on Ofsted’s website”.
The review added that inspectors and support staff “should be fully engaged in the design of Ofsted’s new approach to professional learning and development”.
Ofsted said it fully accepted these recommendations.
2. Train up Ofsted leaders in crisis communications
The review found Ofsted’s initial response to the tragedy “appears defensive and complacent rather than reflective and self-critical”.
The lack of awareness “served to make the coroner’s findings all the more shocking for Ofsted”.
“It 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’s judgments and what they had been told.”
Ofsted should organise a senior leadership development session, involving board members and the executive team, to “work through a range of critical and serious incident scenarios”.
It should “include input from experts on crisis communications”.
National directors, supported by other senior leaders, should “play a leading and authoritative role as the guardian of inspection standards and practice in any future critical or serious incident”. Ofsted said it fully accepted the recommendations.
3. Contract out post-inspection surveys
Gilbert found an “obvious mismatch” between Ofsted’s post-inspection surveys findings and externally-commissioned research carried out for the Big Listen.
Independent external reviews and evaluations should be built into Ofsted’s 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 “budgetary implications” of contracting out post-inspection surveys.
4. Don’t ‘shift the balance’ on safeguarding
Ofsted’s safeguarding changes have been “particularly important”, Gilbert said. For instance, a new hub now fields calls from inspectors about safeguarding.
But “some inspectors talked to this review about their concerns around the impact of additional scrutiny of decision making in this area”.
Gilbert said Ofsted should “ensure 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”.
Ofsted said it fully accepted the recommendation.
5. Embed external oversight in complaints
Changes to complaint procedures have been “well received but there remains a strong feeling that there is far more to do”.
HMIs also reported incidents of senior leaders at inspected providers using the new complaints process to “exert pressure”, Gilbert said.
“Some suggested it would help if there was additional on-site quality assurance from senior inspectors when issues emerge.”
Ofsted should “continue to improve its complaints procedure, with a focus on embedding an element of independent external oversight with the power to re-open inspection judgments”.
Ofsted said it was setting up a “complaints about Ofsted” hub to centralise its process. Complaints panels, which have been piloted, will become permanent.
6. Operate as a ‘unified organisation’
This review found the learning from Perry’s death “was determined, and in some ways constrained, by Ofsted’s organisational structure and culture”.
Its regional structure, introduced in 2013, had “negative consequences”.
Regions were “deliberately set up to be in competition with each other, particularly in Ofsted’s drive to complete the required volume of inspections”.
Inspectors “identified significant differences in style and culture as well as in the operation of terms and conditions”.
Gilbert said there “should be an internal drive for Ofsted to operate as a unified organisation to help ensure a more holistic approach to learning and development” and “should also address inconsistencies in practice.”
Ofsted said it fully accepted the recommendation.
7. Put greater emphasis on performance management
Performance management is “patchy, with staff themselves expressing concerns that poor performance was not always dealt with effectively,” the report said.
The review “heard that, at times, there had been a reluctance to address conduct issues when they were raised, with people ‘getting away with being unpleasant’.”
Ofsted should “place 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”.
Ofsted said it fully accepted the recommendation.
8. Don’t ‘chase’ inspection volume over quality
Inspectors and some senior leaders raised concerns that efforts to learn from the tragedy and give inspections a “more human face” were “undermined by the significant budget cuts the organisation has faced over the last decade and the pressure to complete the volume of required inspections”.
“The review heard the phrase ‘volume trumps quality’ from inspectors, time and time again.”
Gilbert said Ofsted should “review its key performance indicators and the way it drives priorities”. The watchdog accepted that recommendation.
Ofsted should also “advise the DfE and the new government of the dangers associated with chasing inspection volume at the expense of inspection quality”.
The watchdog said it did “not accept that we have chased inspection volumes over inspection quality”.
“We 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 – to the detriment of much else – the quality of inspection.”
9. ‘More sophisticated’ mental health training needed
Ofsted’s work to roll out mental health training in 2024 “should now be built on with more sophisticated training, regularly refreshed”.
This should be “specifically designed to reflect the unique power dynamic of inspection, with specific models and tools to support inspectors to build appropriate relationships during inspection”.
Ofsted said it fully accepted the recommendation.
10. Strengthen board to reduce ‘entitlement’ of chief inspector
This review found the Ofsted board “had little or no involvement in determining the strategy for dealing with the crisis and communicating to the media and stakeholders”.
The board’s role “appears curiously limited, apparently leaving some of Ofsted’s most critical activities outside of its control, unless HMCI chooses to let it have some control”.
“This degree of autonomy and entitlement for HMCI does not make for effective governance.”
Ofsted should review its governance framework to “strengthen the role of the board with the aim of establishing constructive challenge to support Ofsted in its learning and reform”.
Ofsted said it fully accepted the recommendation.
11. Consider wider accountability system, DfE told
As part of its planning for a report card, the government should “initiate a debate about the essential elements of the wider public accountability system, of which Ofsted is a part”.
Ofsted said it agreed with the “spirit” of the recommendation.
