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       Hazards, number 161, 2023
FAILED | HSE’s refusal to act leaves workers in a desperate state
The suicide of headteacher Ruth Perry was a terrible tragedy. But it wasn’t an exception. And like hundreds of other work-related suicides, it will not be investigated, recorded or prosecuted by the Health and Safety Executive (HSE). Hazards examines why suicides linked to work still don’t count.


A single word, ‘inadequate’, was enough. The forthcoming Ofsted downgrading caused headteacher Ruth Perry on 8 January 2023 to take her own life.

A statement from the 53-year-old’s family accused the Ofsted inspectors responsible for the 15-16 November 2022 inspection at Caversham Primary School in Reading of reaching conclusions that were “sensationalist and drawn from scant evidence.” It added: “We are in no doubt that Ruth's death was a direct result of the pressure put on her by the process and outcome of an Ofsted inspection at her school.”

The highly regarded teacher had given 32 years to the profession. Her death led to a unique outpouring of public anger at what was perceived as a blatant and grievous injustice.

But it was not an isolated case.

A deadly pattern

‘Drop dead’, a groundbreaking 2003 Hazards exposé of occupational suicide risks in Britain, featured two examples of deaths linked to Ofsted reports.

Pamela Reif took her own life in January 2000 after being told by Ofsted her lessons ‘lacked pace’. A suicide note said: “I am now finding the stress of my job too much. The pace of work and the long days are more than I can do.” A March 2001 inquest heard 29-year-old teacher James Patton hanged himself because he was worried about a forthcoming Ofsted inspection at his Birmingham primary school.

Since then, Ofsted’s name has been a feature at inquests, according to University of Leeds workplace suicides expert Professor Sarah Waters.

“Ruth’s death was a foreseeable tragedy – a succession of teacher suicides going back over two decades have been linked to inspection pressures,” she told Hazards.

NO LESSONS Despite Ruth Perry’s suicide having a clear link to intolerable work pressures, the Health and Safety Executive (HSE) will not investigate the headteacher’s death.

Prof Waters is co-author of a 2021 paper that examined 12 cases of work-related suicide.

The report noted that in two of the case studies an Ofsted inspection was a contributory factor in the suicide. For one, the suicide of Carol Woodward who was head of Woodford primary school near Plymouth, it was the main causal factor.

The study noted: “A 58-year-old female headteacher of a primary school took her own life in July 2015 shortly after Ofsted downgraded the school to inadequate. The teacher had won a regional primary school Head Teacher of the Year award and the school had previously achieved results that were in the top 5 per cent in England.”

It added: “According to the police report, she experienced a swift mental decline following the inspection. She contacted her GP three times prior to her suicide and told him that the school had failed its inspection and she had let everyone down. The coroner concluded a verdict of suicide and confirmed ‘she just felt she was under so much pressure’.”

The Leeds University report noted: “Recent studies suggest that work-related stressors such as Ofsted inspections and the pressure to perform under the threat of poor Ofsted ratings have been connected to recent suicides.

“Since 1998, coroners’ inquests into the suicides of at least 10 teachers have heard that they took their own life before or after an Ofsted inspection.”

Low grade

Education unions have over years raised concerns about the stressful and 'counterproductive' Ofsted process.

In the wake of Ruth Perry’s suicide, NEU, school leaders’ union NAHT and the Association of School and College Leaders (ASCL) all called for inspections to be paused.

Dr Mary Bousted, the NEU joint general secretary, accusing Ofsted of ‘an absolute lack of empathy’, said: “Ofsted should pause all its inspections and reflect upon the unmanageable and counterproductive stress they cause for school leaders, and the impact on leaders. This stress is well-documented in literature about Ofsted.”

Paul Whiteman, general secretary of NAHT, said: “Whilst it should never take a tragedy like this to prompt action, this has to be a watershed moment,” adding: “It is essential that all policy makers, including Ofsted, listen and respond.”

And Geoff Barton, ASCL general secretary, said: “Ofsted should undertake an immediate review of the impact of inspections on the wellbeing of school and college leaders and staff, and a pause in the inspection cycle would allow for a period in which this could happen.

“The inspectorate must also commit to giving urgent consideration to reform of the inspection system to make it fairer and less punitive. In particular, it must look at replacing the current system of graded judgements which reduce everything that a school or college does to a single blunt descriptor.”

An NEU-led petition calling for Ofsted to be replaced, started before headteacher Ruth Perry took her own life while waiting for publication of Ofsted findings, was submitted to the government on 23 March 2023, with 52,000 signatories.

The 3 April 2023 findings of an NEU survey of almost 18,000 education workers revealed 48 per cent said their workload was unmanageable all or most of the time. More than a third of teachers reported they are stressed 80 per cent or more of the time.

Two-thirds of teachers told NEU they feel this way more than 60 per cent of the time, and almost half of support staff feel stressed more than 60 per cent of the time.
Second on the list of interventions that would have a ‘big positive impact’ on workload pressures, trailing only increased funding (88 per cent), was a “reformed inspection system” (79 per cent).

Total oversight

Ofsted knew there was a problem. In response to pressure from teaching unions, the education watchdog released a clarification document for schools in 2015 to “dispel myths about inspection” that can generate unnecessary workloads in schools.

The Health and Safety Executive (HSE) Education Talking Toolkit issued in light of these concerns makes repeat references to Ofsted and sets out how its Stress Management Standards might be applied to schools in order to reduce stress.

But Prof Waters said despite both Ofsted and HSE being aware of the link between inspections and suicides, “they have done little to change this deeply flawed and dangerous system. They have failed in their responsibility to prevent suicide deaths.”

One key concern is an enforcement anomaly where work-related suicides are not investigated, recorded or subject to enforcement action by HSE.

SUICIDE ACT  Six simple measures could make action to recognise, record and prevent work-related suicides more effective. more

Ruth Perry’s death is undeniably work-related, and might be expected to interest HSE in its role as the sector’s workplace health and safety investigator, regulator and enforcer.

But while an HSE spokesperson told Hazards: “Our thoughts are with everyone who knew Ruth Perry,” they added: “Suicide is not reportable under RIDDOR [the injury and ill-health reporting regulations]. A coroner can refer a case to HSE if they consider there is an ongoing risk to others.”

HSE doesn’t want to know

Hilda Palmer of the national Hazards Campaign described HSE’s response as “an abdication of regulatory responsibility.” She told Hazards: “I have attended many inquests into work-related deaths where HSE evidence has been critical to the coroner’s deliberations and conclusions.

“But because HSE does not ‘do’ suicides, there is no HSE presence at the inquest and no regulator’s guidance for the coroner on the workplace contributors.”

ACTION! Send an e-postcard to HSE demanding it recognise, record and take action to prevent work-related suicides. www.hazards.org/hsesuicide

Prof Waters concurs.

“HSE expects an inquest to substitute for an on-the-ground HSE investigation and coroners instead to provide direction to HSE on if, when and how the regulator might respond to a suicide,” she said.  

“It presupposes we should be satisfied with a system where work-related suicide only merits HSE scrutiny after an inquest into a death recommends that it step in – not because the regulator should as a matter of course investigate suicide like any other work-related death.”

HSE has doggedly defended its official blind-eye to work-related suicide risks because the issue is “too complex” (Hazards 155).

REPEAT TRAGEDIES  The head of the London Fire Brigade (LFB) has apologised personally to the mother of Jaden Francois-Esprit, a firefighter whose suicide triggered a review that found the service to be “institutionally misogynist and racist”. Another review into the suicide death of junior doctor Vaishnavi Kumar concluded there was “a culture that is corrosively affecting morale” at University Hospitals Birmingham (UHB). more

The regulator remains resolutely in the slow lane on recognition and reporting of work-related suicides, lagging behind international best practice, and refuses to include workplace suicides or suicide risks in its inspection, reporting and enforcement management policies.

Palmer, the workplace safety veteran who co-authored the Leeds University study, said: “Suicide, the most desperate consequence of work in an unsupportive or punitive workplace environment, is unconscionably denied scrutiny by the workplace safety regulator.”  

She added: “HSE needs to step up and reverse its self-imposed refusal to protect workers from work-related suicide risks. It must investigate suicide risks at work and work-related suicides, in the same way it does the other hazards encountered in toxic workplaces.

“HSE’s ‘not us’ stance denies the preventive role the regulator could play in workplaces, through identifying and requiring a remedy for suicide risk factors.”




Making work suicides count

Six simple measures could make action to recognise, record and prevent work-related suicides more effective.

  • Count them Make work-related suicide reportable under the RIDDOR regulations and improve communication between the Health and Safety Executive (HSE) and coroners on potential work-related suicide notification.

  • Define them Suicides caused by or clearly related to work need to be clearly defined. This could include suicide at work, in work clothes or using work equipment or materials, referrals to occupational health or HR for mental health problems, a history of mental health-related sick leave, a pattern of stress-related problems affecting co-workers, evidence from personal documentation, coroners’ inquests, GPs and other health professionals, or family or suicide notes implicating work factors.

  • Assess them Investigating and addressing suicide risks should be part of workplace stress risk assessments and stress management strategies.

  • Investigate them Work-related suicide and suicide ideation should be included explicitly in HSE’s inspection guidelines. There should be HSE operational guidelines for inspectors on work-related stress, including work-related suicides. Work-related suicide should be added explicitly to the Work-related Deaths Protocol defining cooperative arrangements between HSE, police, prosecutors and other investigating and statutory agencies.

  • Prioritise them Suicide meets the requirement for inclusion in HSE’s Matters of Evident Concern and Potential Major Concern (Hazards 155). The Operational Circular to inspectors should be applied to suicides, and trigger HSE investigations into work-related suicides, suicide patterns or evidence of suicide ideation (suicidal thoughts)

  • Compensate them. Deaths from work-related suicide should, in line with other fatal work-related conditions like mesothelioma, be eligible for government compensation. Legal guidance should clarify to courts the potential for work-related suicide causation in civil compensation cases.


More suicides, more apologies, no justice

The head of the London Fire Brigade (LFB) has apologised personally to the mother of a black firefighter whose suicide triggered a review of the service and found it to be “institutionally misogynist and racist”.

The review was launched by the London fire commissioner, Andy Roe, in response to the death of Jaden Francois-Esprit (above), who was neurodiverse and who took his own life aged 21 in August 2020. Speaking at a meeting of the London assembly’s fire, resilience and emergency planning committee on 1 February 2023, Roe directly addressed Francois-Esprit’s mother, Linda Francois.

“LFB let your son down in almost every aspect,” he said. “In terms of our system, in terms of how he experienced his work day to day…. Seeing you here now, I can only apologise for the public record.” The LFB chief added: “Sadly, Jaden wasn’t the first colleague to take his life. There is a high rate of suicide in the emergency services generally.”

Francois welcomed the apology from Roe and the steps LFB is taking to change its culture. But she said it had more work to do. “Nobody at the station where Jaden worked has been held accountable for what happened to him,” she said. “We want the LFB to connect the dots and I’m not sure they’re doing that.” Roe said the changes he hoped to see in the fire service were not yet embedded. “This is a process of fundamental change.”

Work-related suicides may now be the single largest cause of workplace sudden deaths.

Hospital doctor Vaishnavi Kumar (below), who had won an award for ‘empowerment’ in June 2020, struggled with a “hypercritical environment” at work before the 35-year-old’s suicide in June 2022.

The independent rapid review headed by Prof Mike Bewick was initiated after the suicide of Queen Elizabeth Hospital doctor Vaishnavi Kumar, 35, who had won an award for ‘empowerment’ in June 2020.

Dr Kumar had struggled with a “hypercritical environment” at the Birmingham hospital before killing herself two years later. The review, whose findings were published on 28 March 2023, examined the behaviour of the hospital leadership and concluded there was “a culture that is corrosively affecting morale” at University Hospitals Birmingham (UHB).

In a statement, UHB chief executive Jonathan Brotherton said the Trust accepted the inquiry’s findings and added: “There are a number of significant concerns that we need to, and have started to, address; we will continue to learn from the past, as we move forward.

“We want to develop a positive, inclusive work environment where people want to come to work, in a place that they are proud to work in, to do their very best for our patients. While we will not be able to fix things as quickly as I would like, we do need to do it as quickly as possible, for the benefit of patients and staff; I am committed to ensuring this happens.

“We must now focus on continuing to provide the best possible patient care, building a values-led culture and supporting our incredible colleagues.”

Recent inquests have reported work-related suicides deaths in other occupations. Engineering worker Wayne Mason, 49, was found dead at work on 17 March 2022. He was supposed to be on sick leave for his mental health problems at the time (Hazards 160).

Owain Vaughan Morgan, a government lawyer, had never suffered mental health problems until he was promoted to a more stressful job in January 2020, had a nervous breakdown in May 2020 and killed himself age 44 in April 2021.

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The suicide of headteacher Ruth Perry was a terrible tragedy. But it wasn’t an exception. And like hundreds of other work-related suicides, it will not be investigated, recorded or prosecuted by the Health and Safety Executive (HSE). Hazards examines why suicides linked to work still don’t count.

A deadly pattern
Low grade
Total oversight
HSE doesn’t want to know

Related stories
Making work suicides count
More suicides, more apologies, no justice

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Hazards news
Deadly business


Use the Hazards e-postcard to tell the HSE to recognise, record and take action to prevent work-related suicides.