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RIP HSE | Regulator ignores deadly warnings and suicides at work
It is a tale of two suicides. A hospital doctor kills herself, leaves a note blaming her employer and an inquiry confirms a pervasive ‘toxic culture’ at work. A headteacher kills herself and a coroner rules it is work-related. In both cases the Health and Safety Executive (HSE) failed to act. Hazards editor Rory O’Neill asks ‘What’s the point of HSE?’


Junior doctor Vaish Kumar (below) left a suicide note blaming her death entirely on the hospital where she worked. Coroner Ian Dreelan, at a November 2022 inquest into the doctor’s death, concluded contributory factors including an underlying medical condition and “the family bereavement she had suffered and the work stress she had experienced and mentioned to a clinician when she sought help” (Hazards 160).

But Dr Kumar’s suicide on 22 June 2022 age 35 wasn’t the only indicator something had gone seriously wrong at University Hospitals Birmingham.

Concerns about bullying and harassment at the hospital were widely known. An Independent organisational culture review published in September 2023, informed by input from around 4,000 staff, “found a challenging staff experience that has manifested itself over a long period of time, has largely continued unchecked, and has created a culture where for many, an adverse working environment has become normalised.”

It added: “For many of the staff who engaged with the review, their experience of working in the Trust is compromised, with a range of concerns. These include not feeling valued and respected, often not feeling safe at work, and not connected to the wider organisation in which they serve.”

The review noted: “Many staff at the Trust often felt unsupported, disrespected, and pushed beyond their capacity. This environment has created a culture where these staff feel they are treated like a number on a spreadsheet, and that the best way to get through the day is to keep their head down without confronting or challenging the status quo; to avoid becoming an outlier. This is clearly having an impact on psychological wellbeing, with many staff expressing a significant impact on their mental health and general wellbeing.”

A response from the hospital trust included an apology for ‘unacceptable behaviours’ and an acceptance there was an embedded problem of ‘unsafe’ work practices and psychosocial health risks. It added: “We are committed to developing a psychologically safe, positive, and 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.”

In the period between Dr Kumar in 2019 first raising concerns about her mental health at work and taking her life in 2022, the Health and Safety Executive (HSE) visited University Hospitals Birmingham five times, a freedom of information request from Hazards has revealed. On each occasion HSE reported ‘no breach’ of health and safety laws and reported ‘no further action.’

Then a worker died by suicide.

Throughout the trust was riven with organisational safety problems, something it accepted and for which it apologised. An independent review confirmed many workers were concerned about safety and psychosocial risks and a largely unchecked “adverse working environment” was the norm.

And HSE saw nothing and did nothing.

Missed lessons

The suicide of Ruth Perry (below) has attracted national headlines and led to severe pressure on Ofsted to reform its practices. An Ofsted inspection “likely contributed” to the death of the head teacher, an inquest ruled on 7 December 2023. The inspection of Caversham Primary School, in Reading, “lacked fairness, respect and sensitivity” and was at times “rude and intimidating,” senior coroner Heidi Connor said.

It was downgraded from outstanding to “inadequate” due solely to safeguarding concerns after the Ofsted visit in November 2022 (Hazards 161). The school has since been re-graded as “good”.

In the weeks after the inspection, Ruth wrote a series of notes, later found by her family, revealing the turmoil she was going through. She was “devastated” and “heartbroken.”

“I do not believe any child has been harmed because I have been negligent in my duties,” she wrote.

Over the following days, Ruth rehearsed breaking the news that the school has been rated “inadequate.” She wrote: “I write this to you as parents on the evening of 18th November 2022 to say how utterly broken I am by the Ofsted inspection. I have given my life to CPS [Caversham Primary School]. I have only ever wanted children to leave happy and confident on the next stage of their journey, and I have been devastated by the impact of how I have done a disservice to the community.”

Ruth, 53, took her own life on 8 January 2023 while waiting for the Ofsted report to be published. The coroner noted medical and other records examined at the inquest “make it abundantly clear that the Ofsted inspection was the reason for her sudden mental health deterioration. Apart from some anxiety medication 30 years previously, Ruth had no recorded mental health history.”

FAMILY FURY Julia Waters, Ruth Perry's sister, expressed anger at Ofsted's failure to address the stress its inspections cause to school staff. She said the regulator 'is a total shambles.'

The coroner noted: “I find very easily that Ruth's mental health deterioration and death was likely contributed to by the Ofsted inspection.” But she added this “was not the only cause.” Other causes highlighted by the coroner included the system of single work judgments, confidentiality requirement and the length of time between the inspection and the final report.

In her verdict, Ms Connor reiterated: “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.” Her verdict stated: “Ruth Perry was a headteacher at Caversham Primary School, Reading in Berkshire. She had no relevant mental health history. An Ofsted inspection took place on 15 and 16 November 2022. During and after this inspection, Ruth's mental health deteriorated significantly. Ruth took her own life on 8 January 2023. She was declared deceased at the Royal Berkshire Hospital, in Reading, that day”.

Her conclusion was stark: “Suicide, contributed to by an Ofsted inspection carried out in November.”

WE DESPAIR HSE action on suicides could save lives; it just doesn’t want to to. More.

In March 2023, Hazards asked HSE, in the light of emerging evidence Ruth Perry’s death may be work-related and as the relevant regulator if it was “investigating or planning to investigate this death?”

An HSE spokesperson responded: “Our thoughts are with everyone who knew Ruth Perry. Suicide is not reportable under RIDDOR. A coroner can refer a case to HSE if they consider there is an ongoing risk to others.”


Suicidal oversight

The suicides of Vaish Kumar and Ruth Perry illustrate different but complementary failings by HSE.

HSE visited Vaish’s hospital workplaces five times while she was experiencing work-related mental turmoil in an environment believed by its workforce to be psychosocially unsafe, a belief confirmed by an independent review. There were grounds to believe that a rapid deterioration in Ruth Perry’s mental health after the Ofsted inspection pointed to a work-related cause.

MISSED OPPORTUNITIES Suicides linked to work are not rare. Hazards looks at some recent cases. More

Figures announced by HSE on 22 November 2023 revealed work-related ill-health has remained at an all-time high, and work-related stress, depression and anxiety top the list of problems, accounting for around half of all cases. An estimated 875,000 workers were affected in 2022/23. Some will have had relatively minor problems. But for others the problem was inevitably serious and a potential contributor to suicides.

Tackling the runaway psychosocial crisis at work should be top of HSE’s priorities. But even the most blatant and potentially deadly cases are ignored. Instead, HSE sits waiting for a Prevention of Future Deaths (FDR) report from coroners after the fact, a report that will never come.

A Hazards analysis of coroners’ records showed not a single work-related suicide case had ever been reported by a coroner to HSE

Even is the case of Ruth Perry, where the death was recognised by the coroner as related to her job, the focus of the related 12 December 2023 Prevention of Future Deaths report was narrow and only considered what Ofsted did wrong, rather than HSE’s wholesale failure to investigate the causes and from that recommend the organisational changes that could improve prevention.

Ruth’s death was linked directly to the work she did. And HSE, the workplace regulator, was nowhere to be seen.



Teaching unions call for urgent change

Teaching unions have called for the Ofsted system to be reformed after the schools regulator was excoriated by a coroner.

Ruth Perry’s suicide, senior coroner Heidi Connor said, was “contributed to by an Ofsted inspection”, adding  parts of the inspection were “rude and intimidating”.

The coroner did not regard Ofsted witnesses as truthful, the unions noted. The coroner described the claim the schools regulator made under oath that “school inspections can be paused if the distress of a headteacher is a concern” as “a mythical creature created and expanded upon at this inquest.”

Prior to the inquest concluding on 7 December 2023, Ofsted chief inspector Amanda Spielman said Mrs Perry's death had been used to "discredit" the schools watchdog. Referring to these comments, Ms Connor said this suggests a lack of learning from this case. In her response to the verdict, Spielman maintained that Ofsted has a “deep understanding of the work that schools do and the demands on school leaders”.

Jo Grady, general secretary of the university lecturers’ union UCU, commented: "The tragic and disturbing case of Ruth Perry sadly serves to illustrate the problems in the way that Ofsted acts and its effects on staff. The crude judgments published, the confrontational way in which inspections are conducted, and the pressure that they heap on staff, are not fit for purpose.

“We believe that accountability could be better provided through a system based on peer challenge and aimed at fostering real improvement within institutions. Ofsted should be replaced and the toxic culture it encourages rooted out."

Paul Whiteman, general secretary of the National Association of Head Teachers, and Geoff Barton, general secretary of the Association of School and College Leaders,  issued a joint statement in the wake of the coroner’s conclusions. They said: “We are calling for an immediate pause to Ofsted inspections to allow time for meaningful action to be taken to address the concerns raised by the coroner in the inquest into the death of Ruth Perry.

“The coroner set out seven areas of concern for her Regulation 28 Report to prevent future deaths. It is important that we have clarity from Ofsted about a plan and timetable to address each area before further inspections take place. This is vital in reassuring schools and colleges that appropriate steps are being taken to protect and support the welfare of education staff.”

The unions said a statement from Ofsted chief inspector Amanda Spielman outlining some steps in response to the coroner’s concerns including a delay to inspections of a single day to bring together lead school inspectors they "do not think this goes nearly far enough. We will be writing to education secretary Gillian Keegan and the chief inspector formally requesting an immediate pause to inspections to give space for proper consideration. This is necessary for schools and colleges to have even a modicum of confidence in the inspectorate.

“We have also spoken about our concerns to the incoming Chief Inspector, Sir Martyn Oliver, who begins his term of office in January [2024], and we have arranged for a formal meeting with him as soon as he takes up his post.”

Teaching union NEU called “for urgent measures and immediate changes in response to the coroner’s verdict and conclusions. Ofsted’s inspections of schools must be paused not for a day but a longer period, until a better model of accountability and school improvement can be developed.” NEU added: “We are in desperate need of a system that is fair, supportive and constructive. The age of adversarial inspection has passed.”

The inquest heard Ofsted training for its inspectors on dealing with the stress to headteachers resulting from inspections was limited to a two-minute slot which also covered other issues. The evident shock at this provision prompted Ofsted to arrange a short one-off briefing for its lead inspectors to address concerns raised by the head-teacher’s suicide.

Ruth Perry’s family called on the Ofsted chief inspector to resign immediately after it was revealed its lead inspectors will spend just 90 minutes on a briefing to address these concerns raised by the headteacher’s suicide.

Julia Waters (above), Perry’s sister, said the “shocking” response showed that Amanda Spielman had “lost the plot” as chief inspector and should resign now ahead of her term finishing at the end of the year. An internal Ofsted memo, shows that the “national briefing” to deal with the issues of headteacher stress raised at the inquest would be just a 90-minute online webinar and Q&A session, followed by a 30-minute regional “forum for follow-up” online meeting.

Waters said: “I would say it is shocking, if we didn’t know what we know now about Ofsted. Ofsted is a total shambles, and its leaders are out of touch with reality.” She added: “If this was Amanda Spielman trying to show she is taking action in response to a damning coroner’s conclusion, then she has clearly lost the plot as well as running out of ideas… She should quit now and let someone else get on with it.”



Sexual harassment led to teen soldier’s suicide

A 19-year-old soldier is believed to have taken her own life after sexual harassment from her boss, according to an internal army inquiry report. Royal Artillery Gunner Jaysley Beck (right) was found dead at Larkhill Camp in Wiltshire in December 2021 after experiencing “an intense period of unwelcome behaviour”, the inquiry report said.

The MoD internal review published in October 2023 details how Beck received more than 1,000 messages and voicemails from her boss in October 2021. In November, the messages increased to more than 3,500. The boss is not named in the report. “It is almost certain this was a causal factor in her death,” the report said. In the weeks before her death, she messaged her boss to say: “I can’t handle it any more. It’s weighing me down.”

The report found significant evidence of inappropriate sexual behaviour from male soldiers towards female soldiers at the Larkhill garrison, with one witness describing routinely receiving comments from male soldiers that were “vile” and “degrading”, according to the Centre for Military Justice (CMJ), which is representing the family. It said Jaysley died after a ‘relentless’ campaign of sexual harassment.

In July 2021, Beck had been sexually assaulted by a warrant officer while on exercises. The CMJ said the incident was reported but not referred to police, and there “appears to have been no meaningful investigation”. In a letter of apology to Beck after the incident, the perpetrator wrote his “door will always be open,” according to the CMJ.

Chef died after long hours led to mental problems

A successful chef died after being hit by a train following work-related stress, an inquest heard. Anthony Michael Flanagan, 44, was working 80-hour weeks as a chef leading up to his death at Sherborne rail station.

In 31 July 2022, he was travelling home to Bolton, Lancashire after working away in Devon but suffered from a mental health decline during his journey. He used an emergency phone line in Exeter to alert emergency services that he was feeling suicidal.

Later that day a train driver reported that a man who had been hidden in bushes had emerged in front of his train. Mr Flanagan was later identified, and a post-mortem by Dr Simon Rasbridge confirmed he died from multiple injuries.

At an inquest held at Bournemouth Town Hall on 9 November 2023, area coroner for Dorset, Brendan Allen, noted that in the weeks leading to his death, Mr Flanagan had been working between 65 to 85 hours a week. The coroner concluded that at the time of his death he intended to take his life and died as a result of suicide.

Firefighter killed himself after watch change

A firefighter took his own life, with colleagues noting he had appeared down after moving to a new watch. Colin Speight (right), who worked at both Glenrothes and Cupar fire stations, was 47 when he killed himself in December 2021.

Fire service colleague Gordon Nimmo was at Speight's family home when the police arrived to tell them about his death – and broke the news to his friend's mother. “You deal with a lot of stuff in the fire service... you deal with fatalities and stuff like that. But you don't have to deal with seeing your friend's mum getting told how they found her son,” he said.

Speight's family and friends were aware he was going through a difficult time, but his death came as a shock. His co-workers noted he struggled a bit when he moved to a new watch. His friend Gordon Nimmo commented: “He put up a mental health board, with posters and advice and all short things. That was his, he put that forward.”

“You do see some pretty horrible stuff and it's quite easy to be detached from these things, but [people] can only take so much,” Mr Nimmo said.

Care home worker struggled at work

A care home worker was found dead after he had been struggling with his new role at work, an inquest has heard.  Jason Burridge, 51, had been promoted to a managerial role at Aykroyd Lodge care home in Reedley earlier in the year and the inquest at Accrington Town Hall heard he was “highly thought-of” by senior members of staff at the care provider.

Victoria Norris, Jason’s line manager, said she was approached by Jason around January or February 2023 when he expressed concerns about the paperwork element of the job and was considering stepping down. At the end of April Jason said the situation had improved but he still felt like he wanted to step down, but agreed to remain in post while an alternative manager was found.

An unexplained incident happened at the care home while Jason was not on shift but, due to his position as manager, he shouldered a lot of the blame.  Following this he sought help from his GP and mental health services.

He was found dead on 18 July 2023, with coroner Richard Taylor recording a verdict of suicide.


'Overworked' actress in Japan took her own life

A prestigious Japanese all-female theatre company has admitted it feels responsible for the death of a young actress whose suspected suicide was reportedly caused by overwork. Executives from Takarazuka Revue apologised for “loss of life” of the unnamed 25-year-old performer. Chairman Kenshi Koba also said he was stepping down.

“It is undeniable that a strong psychological burden was placed on [the woman], and we did not sufficiently fulfil our duty of care for her safety,” Mr Koba told a news conference at the revue's base in the western city of Takarazuka. Addressing relatives, he said: “We deeply apologise for not being able to protect a precious member of your family.”

The actress was found dead in her condominium in Takarazuka on 30 September 2023. Police said she died of suspected suicide. Suicide linked to overwork – karojisatsu – is a state recognised and compensated occupational condition in Japan

Her family are suing the company for compensation. The actress took her own life because the overworking and bullying by her seniors “compromised her mental and physical health,” her family's lawyer said. The lawyer said she was under an outsourcing contract with the company and that her overtime exceeded 277 hours a month, which was above the government's criteria for worker compensation.

Takarazuka Revue has put the figure at 118 hours a month.

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It is a tale of two suicides. A hospital doctor kills herself, leaves a note blaming her employer and an inquiry confirms a pervasive ‘toxic culture’ at work. A headteacher kills herself and a coroner rules it is work-related. In both cases the Health and Safety Executive (HSE) failed to act. Hazards editor Rory O’Neill asks ‘What’s the point of HSE?’.

Missed lessons
Suicidal oversight
We despair

Teaching unions call for urgent change
Hazards workplace suicide casefile
  • Jaysley Beck 
  • Anthony Michael Flanagan
  • Colin Speight
  • Jason Burridge
'Overworked' actress in Japan took her life

Hazards webpages
Deadly business
Work suicide

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