Ofsted’s initial response to the death of headteacher Ruth Perry appeared “defensive and complacent”, an independent review has concluded.

Dame Christine Gilbert, who led the independent learning review, said the culture of the education watchdog needs to be “more open” if Ofsted is to fully learn from the tragedy of Mrs Perry’s death.

Mrs Perry took her own life after an Ofsted report downgraded her Caversham Primary School in Reading from its highest rating of “outstanding” to its lowest rating – “inadequate” – over safeguarding concerns.

A coroner concluded the Ofsted inspection in November 2022 “contributed” to Mrs Perry’s death.

Dame Christine, a former Ofsted chief inspector, led the review in response to the coroner’s Prevention of Future Deaths report from Mrs Perry’s inquest.

The report, published on Tuesday, said: “Looking back, Ofsted’s initial response appears defensive and complacent rather than reflective and self-critical.

“This 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.

“However, it has led to a changing approach to communications within Ofsted, including inviting feedback and criticism to support improved practice.”

It added: “If Ofsted’s obvious determination to learn from the tragedy of Ruth Perry’s death is to be fully realised and sustained, the board must ensure that the culture of the organisation is more open.”

The watchdog has come under greater scrutiny after the death of Mrs Perry.

On Tuesday, Ofsted announced a series of reforms to England’s education inspectorate following its Big Listen public consultation.

The review noted that the criticism of Ofsted in recent years has had an impact on the morale of some inspectors.

It said: “Some current HMIs reported no longer telling people they met that they worked for Ofsted and were worried about being on social media for fear of personal vilification.

“They had received some advice on personal safety from their managers following the tragedy and some had sought individual help.

“Nevertheless, the danger is that low morale puts further pressure on retention and the quality of inspection.”

The review by Dame Christine – who served as chief inspector at Ofsted from 2006 until 2011 – did not examine the inspection of Caversham Primary School or the judgments made.

It made a series of recommendations – which included ensuring that Ofsted’s actions following the coroner’s report continue with “a sense of urgency”.

Mrs Perry’s sister, Professor Julia Waters, said: “Dame Christine Gilbert’s learning review is highly critical of Ofsted’s culture and practices in many places.

“It highlights how Ofsted’s response to my sister’s death appeared defensive and complacent. She reveals a culture that has allowed inspectors to come across as remote and infallible, with an unfair power balance between inspectors and those they inspect.

“I am glad that Ofsted has accepted the majority of Dame Christine’s recommendations. I am concerned that Ofsted does not appear willing to consider more independent handling of complaints. This would add the prospect of important external scrutiny of the conduct of Ofsted inspectors and their findings.

“After a Big Listen, we have now been promised big change. Ofsted can have no more excuses.”

Sir Martyn Oliver, chief inspector of Ofsted, said: “I’m immensely grateful to Dame Christine Gilbert for conducting an independent and rigorous inspection.

“Because of her knowledge she’s clearly been able to go very deeply into Ofsted and produced for me a really reflective and useful report going forward.

“I found most of it chimed with the rest of the Big Listen, and in many ways set it out in a really succinct way.”

Paul Whiteman, general secretary of school leaders’ union the NAHT, said: “Change to how inspections are carried out in England is now inevitable and unavoidable.

“We need to work towards a more humane and fair system as quickly as possible.

“That work cannot be carried out in isolation by the inspectorate. It must be carried out in partnership with the profession, and we stand ready to play our part in building a fairer, more humane inspection system.”