Jim Clifford responds to the coroner’s findings about the death of Ruth Perry, which she linked to the Ofsted Inspection which contributed to it.  He suggests that this is not an isolated tragedy, but a malaise cutting to the heart of how we design public service systems – with the wrong mindset and a deep lack of insight into the effects those systems are having.  It is time for change: a radical re-thinking, with humility, and a genuine keenness to learn.


This needs a more radical solution.  “Inadequate” insight and the wrong mindset lead to designing public service systems that harm rather than protect and improve.  We need to rethink – really re-think – how we design public services.

In this last week we heard the coroner’s conclusion on the inquest for Ruth Perry, the former very successful headteacher at Caversham Primary School.  Faced with a downgrading of her school to Inadequate from Outstanding, and having to carry that herself for the three month Ofsted confidentiality period she took her own life.  The Berkshire Senior Coroner, Heidi Connor concluded that the inspection “lacked fairness, respect and sensitivity” and was at times “rude and intimidating”.  She heard evidence from Mrs Perry’s GP, from teachers at the school, and from others, linking her death to this one event in her life.  Her conclusion was that the inspection “likely contributed” to Mrs Perry’s death.

There are no words to describe this tragedy…

That this is the first time that a coroner has cited an Ofsted Inspection as the sole contributing factor in a suicide.  In June, a matter of months after Mrs Perry’s death, the school was regraded ‘Good’.  The BBC referred to the Inspector’s report which said “the school’s work to address previous weaknesses has been swift, thorough and effective”.  It really does beg whether a one-word regrading helps anyone, or whether it would be better to put in support to tackle the one or two areas of focus – the School Improvement Partners, for example, who’ve been around for over ten years.

Ofsted’s Chief Inspector has explained how Ofsted is reacting to this, but is still defending the single word grading system.  Yet former Chief Inspector Sir Michael Wilshaw in June came out in favour of scrapping the system in favour of a more nuanced report.

A society in crisis

It is shocking that we, as a society, have allowed a mental health crisis to develop across the teaching profession. It’s been decades in the making, but the latest figures from Education Support make for grim reading.  In his blog “Choosing with Heart: The Journey of Education in Modern Time”, Chris Theobald, suggests that part of the cause is the narrowly focused pressure applied to achieve arbitrarily set standards, rather than celebrating when each individual has reached their potential and has excelled in the things they enjoy and want to do.

I have experienced leading an organisation through an Ofsted inspection.  Even with a helpful and sensitive inspector it worried me sick!  I have also, with our Sonnet team, explored and assessed the mental health support environment across the North of England coming out of COVID lockdowns.  In the latter, reflecting the findings in other work we have done, it was clear that the systems around people in need led to direct harm, or worsened their situation and hampered the support being offered by charities, GPs and others.  Why was this happening: surely the systems weren’t designed to hurt ?

The model emerging from Sonnet’s analysis

In the model emerging from our analysis we recognised that:

  • Many were focusing on the effects of the systems, and trying to soothe and heal
  • Yet the effects of the system happened because of events – how could we stop them happening?
  • These events happened because of the behaviours of those involved in service delivery
  • Those involved in service delivery, didn’t intend harm, but were delivering the systems in the way they were designed, and the roles within that system which they had been allocated
  • And the systems were designed in that way because of a mindset or understanding, often based on inadequate insight and research, and not updated when it became apparent it wasn’t delivering something positive.

This resonates for me when looking at Ofsted Inspection and Grading.  It also does when looking at the system for assessing eligibility for Personal Independence Payments to pick just one other caustic Public Service System.  It seems that, like Ofsted, it is designed from the wrong mindset.  Where the introduction to it on ‘gov.uk’ talks about how it can “help” people who need it, the assessment process appears to ignore evidence, make unsubstantiated judgments, and deny people’s right to show their need.  It is hardly surprising that – still – 69% of negative assessments are reversed on appeal…and that’s not a tiny number of cases either.

Re-thinking how we design systems in public services

We could look at other systems as well (and do ask if you want more), but my point is this:  it’s time for a real rethinking of how we design systems in public services.  Every such system needs to be built from a real understanding of what is needed by the people entitled to be helped, and their situations.  That research should be published, and those who support them should have real opportunity to contribute – note I didn’t say ‘comment’.  Systems should be co-designed by those with real insight into how such systems work, and how they affect the people caught up in them.  Public service systems should help those involved, not impose damaging controls based on imagined risks and a deep lack of understanding of what is going on.

I call on Public Services – notably including Ofsted – to listen with humility, to focus on meeting real need, and to recognise with sensitivity and forethought how what they design can enhance or harm.


Jim Clifford, CEO

Published On: December 11th, 2023Categories: BlogBy

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