An Ofsted inspection “likely contributed” to the death of headteacher Ruth Perry, a coroner has concluded.

Mrs Perry took her own life after a report from the watchdog downgraded her Caversham Primary School in Reading from its highest rating to its lowest over safeguarding concerns.

Staff at the school said the headteacher was left tearful and incoherent after the inspection on November 15 and 16 last year.

Her husband, Jonathan Perry, previously told the inquest his wife felt “completely devastated” in the weeks following the inspection, and that she worried about the impact of the school’s downgrading on the local community.

Mrs Perry’s GP, Tom Back, also said he believed there was a “link” between the inspection and the headteacher’s mental health deterioration and death, adding it contributed “in a more than minimal way”.

Concluding her inquest in Reading, senior coroner Heidi Connor said: “The evidence is clear in this respect, and I find that Ruth’s mental health deterioration and death was likely contributed to by the Ofsted inspection.”

The inquiry heard Ofsted’s Alan Derry, who led the inspection at the school, said Mrs Perry was “tearful” and kept saying “it’s not looking good is it?”.

Parts of this inspection were, in my view, very much done 'to' rather than 'with' this school

Mr Perry told the inquest his wife felt the Ofsted inspector was a “bully” with an “agenda”.

He said she was concerned failing on child safeguarding would be the end of her career.

Ms Connor said: “I find that parts of the Ofsted inspection were conducted in a way which lacked fairness, respect and sensitivity.”

She said that this “likely” had an impact on Mrs Perry’s ability to deal with the inspection process.

“Parts of this inspection were, in my view, very much done ‘to’ rather than ‘with’ this school,” she said.

“I recall asking questions of Ofsted about this. I put it to them that some people instinctively know how to deal with another person who is upset.

“Others may not have this instinct, and some perhaps may themselves be unaware of the impact of their own personal style. I do wonder if that is the case here.”

She added a claim made by Ofsted during the inquest, that school inspections can be paused if the distress of a headteacher is a concern, was “a mythical creature”.

“Ofsted gave evidence under oath that they have paused inspections before for reasons of headteacher distress”, she said.

“I heard no direct evidence of this, and I am afraid I have to wonder what the level of distress must have been in those cases for such an action to be taken. It is clear that there is no guidance or training in this respect.”

Ms Connor then turned to what could be done to prevent deaths such as Mrs Perry’s in the future.

The composure and dignity you (Mrs Perry's family) have displayed throughout is remarkable. She is your Ruth, not our Ruth

She said that Ofsted’s aspiration to “assist” parents with their school inspections and grading system, should be “balanced against the safeguarding of the teachers involved in inspections”.

The senior coroner said she was “concerned to note the almost complete absence of Ofsted training” in situations where school leaders showed distress during an inspection, and around whether inspections could be paused in such cases.

She said that she intended to issue a Regulation 28 report to prevent future deaths in this matter, and that she hoped this would assist the parliamentary inquiry into Ofsted inspections.

Turning to Mrs Perry’s family, the coroner said: “The composure and dignity you have displayed throughout is remarkable.

“She is your Ruth, not our Ruth.”

A statement from Mr Perry was read out in court.

Inspections too often have a devastating impact on the mental health and well-being of leaders and staff and drive people out of a profession where recruitment and retention is in a state of crisis

He said that he first laid eyes on his future wife when he was 12 years old.

“I thought to myself, one day I am going to marry that girl.

“Many years later I did.”

He said that his wife was “the best thing in my life”.

“I was proud to be Ruth’s husband,” he said.

“Marrying Ruth was the best thing I have ever done.”

An inspection report, published on Ofsted’s website in March, found Mrs Perry’s school to be “good” in every category apart from leadership and management, where it was judged to be “inadequate”.

Inspectors said school leaders did not have the “required knowledge to keep pupils safe from harm”, did not take “prompt and proper actions” and had not ensured safeguarding was “effective”.

We now need urgent change. Ofsted has no choice but to seriously reflect and make changes to ensure a tragedy like this never happens again

Union leaders said the coroner’s conclusion “must be a catalyst for change”.

Geoff Barton, general secretary of the Association of School and College Leaders, said: “Inspections too often have a devastating impact on the mental health and well-being of leaders and staff and drive people out of a profession where recruitment and retention is in a state of crisis.

“We absolutely recognise and support the need for public accountability, but it does not need to break people in the way the current system does.

“Replacing the current system of graded judgments with a narrative approach would remove a pressure valve which drives stress and anxiety, while also giving parents a fuller picture of provision.

“This is a decision which is beyond the remit of Ofsted and it is up to the Government to make this important change. It is essential that it now acts.”

Paul Whiteman, general secretary of the National Association of Head Teachers (NAHT) union, said: “We now need urgent change. Ofsted has no choice but to seriously reflect and make changes to ensure a tragedy like this never happens again.”