In the UK, inquests and public inquiries serve as crucial mechanisms for examining significant events and tragedies and to help prevent similar incidents from happening again.
Recent high-profile cases have captured national attention, revealing both systemic issues and the profound impact these investigations have on individuals and communities. This article explores two prominent cases - the Ruth Perry inquest and the Grenfell Tower inquiry.
The Ruth Perry inquest, held in 2023, investigated the tragic death of Ruth Perry, a school headteacher who took her own life whilst awaiting the publication of an Ofsted inspection report. Perry had been informed following the inspection that her school would be downgraded from ‘outstanding’ to ‘inadequate’ due to safeguarding concerns. At the time, Ofsted’s inspection processes automatically resulted in an ‘inadequate’ grading when any safeguarding concerns were identified, regardless of how quickly the concerns could be addressed prior to the publication of a report, and despite the fact that a school was performing well in all other areas.
The inquest delved into the circumstances surrounding Perry’s death, examining her work environment, mental health deterioration, and the support systems available to her during and after the inspection process. Testimonies from colleagues and family members painted a picture of an individual under immense pressure, exacerbated by systemic issues within the educational system.
The coroner noted that the intense pressure and distress felt from the Ofsted inspection contributed to Ruth Perry’s mental health deterioration, ultimately concluding that the inspection played a role in her suicide. The official inquest conclusion was ‘suicide: contributed to by an Ofsted inspection carried out in November 2022’.
Key findings from the inquest highlighted significant gaps in support for educators facing mental health challenges, as well as systemic and procedural issues surrounding Ofsted’s inspection processes. In December 2023, the coroner issued a Prevention of Future Deaths (PFD) report to Ofsted, the department for education and Perry’s employer recommending action to be taken.
In response, all recipients of the PFD report committed to implementing various measures to address the coroner’s concerns, including policy and procedural changes and further staff training related to mental health and managing school leader anxiety around inspections. A copy of the PFD report and each response can be found here.
Of particular note, on 2 September 2024 it was confirmed that Ofsted’s one or two-word inspection grades for English schools would be scrapped immediately. Schools will no longer receive ‘outstanding,’ ‘good,’ ‘requires improvement,’ or ‘inadequate’ grades. While schools will still be inspected against the same standards, the change is expected to result in more detailed feedback that reflects the complexities of each school’s situation, rather than reducing it to a single, potentially harmful label.
The outcome of the Ruth Perry inquest also sparked an independent learning review commissioned by Ofsted. The review, published on 3 September 2024, has been completed by Dame Christine Gilbert and is critical of Ofsted’s systems and procedures.
Gilbert concludes that ‘reform is needed to develop an approach to accountability that lessens the unnecessary pressures associated with inspection and supports school leaders in shaping development that improves the lives of children and learners”. She sets out 14 further recommendations to drive further change, which Ofsted has responded to. A copy of the Independent Learning Review and Ofsted’s response can be located here.
The Grenfell Tower inquiry has been one of the most significant public inquiries in recent years. The fire at Grenfell Tower claimed 72 lives, left over 70 people injured and caused extensive damage to the high-rise accommodation building, leading to widespread criticism of building safety regulations and emergency response procedures.
The inquiry was divided into two phases. The first phase focused on the immediate causes of the fire and the events of that night, while the second phase examined the broader issues, including the regulatory framework, building safety standards, and the response from various agencies.
Key revelations from the inquiry have included failures in fire safety practices, inadequate building regulations, and deficiencies in emergency response. Testimonies from survivors, firefighters, and experts have painted a picture of a building that was poorly managed and inadequately protected against fire hazards.
The inquiry led to national debate and has sparked substantial reforms to improve building safety standards and emergency preparedness across the UK, aiming to prevent a repeat of the tragedy. Nevertheless, On 4 September 2024, the Grenfell Inquiry Phase 2 report was published, with its findings indicating that despite reforms such as the Fire Safety Act 2021, Building Safety Act 2022, and introduction of the new Building Safety Regulator, further measures are necessary to address regulatory gaps.
The report is a sombre read and serves as a stark reminder that the UK still has significant work to do to guarantee the safety of residential buildings, especially those at higher risk of fire. Whilst indicating that the legislative reforms in recent years are positive, it emphasises that they are insufficient to fully address the deep-rooted issues within the construction and fire safety industries. In light of this, it makes 32 recommendations aimed at overhauling the culture within these industries to ensure that safety is prioritised at all stages of design, construction, maintenance and management. The recommendations also address the need for more rigorous oversight of fire safety professionals and practices, and call for a strengthening of accountability measures, to ensure that those responsible for fire safety failures are held accountable.
For a detailed account of the report and the specific recommendations made, a full copy can be found here.
The Ruth Perry inquest and Grenfell Tower inquiry underscore the importance of transparency in addressing significant events and systemic failures and demonstrate the important role that inquests and inquires have in bringing about necessary change.
The Ruth Perry inquest highlighted critical issues in mental health support for educators and flaws in Ofsted’s inspection processes, while the Grenfell Tower Inquiry exposed serious deficiencies in regulatory frameworks and institutional practices around building and fire safety.
These investigations have not only sought to provide answers and justice for those affected but have driven reform to prevent similar tragedies in the future.
If you’re involved in an inquest or public inquiry and are seeking legal support, please get in touch with the regulatory team.
For more information on the process of inquests and inquiries, please read our detailed guides below.
