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Daniel Pelka: Serious case review finds 'missed opportunities' Daniel Pelka: Serious case review finds 'missed opportunities'
(35 minutes later)
Chances were missed to help a child who was murdered by his mother and her partner after suffering "terrifying and dreadful" abuse, a report has found.Chances were missed to help a child who was murdered by his mother and her partner after suffering "terrifying and dreadful" abuse, a report has found.
A serious case review found Daniel Pelka, four, was "invisible" at times and "no professional tried sufficiently hard enough" to talk to him.A serious case review found Daniel Pelka, four, was "invisible" at times and "no professional tried sufficiently hard enough" to talk to him.
He was starved and beaten for months before he died in March 2012, at his Coventry home.He was starved and beaten for months before he died in March 2012, at his Coventry home.
The review said "critical lessons" must be "translated into action".The review said "critical lessons" must be "translated into action".
Magdelena Luczak, 27, and Mariusz Krezolek, 34, were told they must serve at least 30 years in jail, after being found guilty of murder at Birmingham Crown Court in July.Magdelena Luczak, 27, and Mariusz Krezolek, 34, were told they must serve at least 30 years in jail, after being found guilty of murder at Birmingham Crown Court in July.
'Shocking reading''Shocking reading'
The court heard Daniel saw a doctor in hospital for a broken arm, arrived at school with bruises and facial injuries, and was seen scavenging for food.The court heard Daniel saw a doctor in hospital for a broken arm, arrived at school with bruises and facial injuries, and was seen scavenging for food.
A teaching assistant described him as a "bag of bones" and the trial heard he was "wasting away". At the time of his death the Coventry schoolboy weighed just over a stone-and-a-half (10kg).A teaching assistant described him as a "bag of bones" and the trial heard he was "wasting away". At the time of his death the Coventry schoolboy weighed just over a stone-and-a-half (10kg).
Police were called to 26 separate incidents at the family home, many involving domestic violence and alcohol abuse, the report revealed. Much of the detail that emerged in the trial about the level of abuse Daniel suffered was "completely unknown" to the professionals involved, the review found.
But it found excuses made by Daniel's "controlling" mother were accepted by professionals who came into contact with the family. The review's key findings include:
The report said professionals needed to "think the unthinkable" and act upon what they saw, rather than accept "parental versions of what was happening at home". In March 2008, when Daniel was eight months old he was treated for a minor head wound. In January 2011, when he was three-and-a-half, he was taken to A&E with a fractured arm.
Much of the detail that emerged in the trial about the level of abuse Daniel suffered was "completely unknown" to the professionals, the review found. The review said the hospital "rightly raised immediate concerns about the [fractured arm]" and that a meeting was held to decide if it was caused by a fall from a settee, as Daniel's mother claimed, or was the result of abuse.
Daniel's father moved to the UK from Poland at the end of 2005 and lived with the family until 2008, when his son was aged one. The meeting decided that Luczak's explanation was "plausible".
The report found Daniel's "voice was not heard throughout" because English was not his first language and he lacked confidence. But the report said the reasons for other bruises found on Daniel at the time, which his mother claimed came from bicycle accidents, were not "fully explored".
"Overall there is no record of any conversation held with him by any professional about his home life, his experiences outside of school, his wishes and feelings and of his relationships with his siblings, mother and her male partners," it concluded.
The report said none of the agencies involved could have predicted Daniel's death and found there were "committed attempts" by his school and health professionals to address his "health and behavioural issues" in the months before his death.
But it added: "Too many opportunities were missed for more urgent and purposeful interventions to consider abuse as a possible causation of his problems."
The Children and Families Minister, Edward Timpson, said the report made "shocking reading".The Children and Families Minister, Edward Timpson, said the report made "shocking reading".
"This serious case review lays bare the missing or misdirected interventions of professionals which should have spotted and stopped the abuse that Daniel was suffering," he said."This serious case review lays bare the missing or misdirected interventions of professionals which should have spotted and stopped the abuse that Daniel was suffering," he said.
Mr Timpson said he had written to the Coventry Safeguarding Children Board asking for a clearer analysis as to why the mistakes occurred.Mr Timpson said he had written to the Coventry Safeguarding Children Board asking for a clearer analysis as to why the mistakes occurred.
'Invisible' Daniel
Amy Weir, the board's chair, said she found the report "disheartening, disappointing and generally worrying".Amy Weir, the board's chair, said she found the report "disheartening, disappointing and generally worrying".
Ms Weir said the idea of Daniel being "invisible" was "at the heart of this case".Ms Weir said the idea of Daniel being "invisible" was "at the heart of this case".
"I think for Daniel there's something which we've never fully been able to get to grips with," she said."I think for Daniel there's something which we've never fully been able to get to grips with," she said.
"The issue about Daniel mainly being Polish speaking" should have been overcome and there were "significant issues" about his mother and her ability to try to "hoodwink the professionals", she added."The issue about Daniel mainly being Polish speaking" should have been overcome and there were "significant issues" about his mother and her ability to try to "hoodwink the professionals", she added.
Coventry City Council's chief executive, Martin Reeves, said the city had "never faced such a tragic case".
"We must learn quickly from the lessons and recommendations of the review."
The review found school staff did not link Daniel's physical injuries with their concerns about his apparent obsession with food, which his mother claimed was caused by a medical condition.The review found school staff did not link Daniel's physical injuries with their concerns about his apparent obsession with food, which his mother claimed was caused by a medical condition.
'Rule of optimism'
"Without proactive or consistent action by any professional to engage with him via an interpreter, then his lack of language and low confidence would likely have made it almost impossible for him to reveal the abuse he was suffering at home," the report found."Without proactive or consistent action by any professional to engage with him via an interpreter, then his lack of language and low confidence would likely have made it almost impossible for him to reveal the abuse he was suffering at home," the report found.
Important opportunities were missed on two occasions when Daniel was taken to an accident and emergency department with injuries, the review said.
In March 2008, when Daniel was eight months old he was treated for a minor head wound. In January 2011, when he was three-and-a-half, he was taken to A&E with a fractured arm.
The review said the hospital "rightly raised immediate concerns about the [fractured arm]" and that a meeting was held to decide if it was caused by a fall from a settee, as Daniel's mother claimed, or was the result of abuse.
The meeting decided that Luczak's explanation was "plausible".
But the report said the reasons for other bruises found on Daniel at the time, which his mother claimed came from bicycle accidents, were not "fully explored".
"Overall, the 'rule of optimism' appeared to have prevailed in the professional response to Daniel's fracture and to his other bruises," the case review said."Overall, the 'rule of optimism' appeared to have prevailed in the professional response to Daniel's fracture and to his other bruises," the case review said.
"In consideration of whether his tragic death was predictable or preventable, it could be argued that had a much more enquiring mind been employed by professionals about [his] care, and they were more focussed and determined in their intentions to address those concerns, this would likely have offered greater protection for Daniel," "In consideration of whether his tragic death was predictable or preventable, it could be argued that had a much more enquiring mind been employed by professionals about [his] care, and they were more focussed and determined in their intentions to address those concerns, this would likely have offered greater protection for Daniel."
'Lack of real action' No-one disciplined
Peter Wanless, the NSPCC's chief executive officer, said: "It's important to remember that only two people are ultimately responsible for little Daniel Pelka's death - his mother and her partner. Sharon Binyon, medical director of the Coventry and Warwickshire Partnership NHS Trust said the service as a whole did not do enough.
"However, it's right that we look at missed opportunities and what could have been done differently. Whilst this SCR judges that no single, specific failure led to his death, time and again we see a basic lack of real action to protect Daniel. Processes were followed correctly much of the time but processes alone do not save children. "Coventry has one of the lowest numbers of health visitors per child in the country. That was recognised and we're working with NHS England," she said.
"Excuses from Daniel's violent, drug using and alcoholic parents were believed. Too often people failed to look at Daniel like they would their own child. "Since the time of Daniel's death the number of health visitors has now doubled and we expect to see it trebled by 2015."
"He was clearly not okay and it's not clear if anyone sought to establish his feelings with him in his own language as his parents' excuses just didn't add up. " Ms Binyon added no-one had been disciplined following Daniel's death.
Peter Wanless, the NSPCC's chief executive officer, said ultimately Daniel's mother and her partner were responsible his death.
"However, it's right that we look at missed opportunities and what could have been done differently," said Mr Wanless.
"Processes were followed correctly much of the time but processes alone do not save children."