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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). |
| 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. | 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. |
| The review's key findings include: | The review's key findings include: |
| 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. | 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 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". | 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". | 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". |
| 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 | '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". | 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." | "We must learn quickly from the lessons and recommendations of the review." |
| Assistant Chief Constable Garry Forsyth, of West Midlands Police, said: "We accept that Daniel was not 'given a voice'." | |
| "The report raised the lack of consistency in dealing with separate domestic abuse reports and in risk assessing each incident. | |
| "We accept there needs to be a more holistic approach when dealing with multiple incidents involving domestic abuse, in particular where children reside." | |
| 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. |
| "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. |
| "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." |
| Gill Mulhall, Daniel's head teacher at Little Heath Primary in Coventry, said: "His mother was a convincing manipulator. | |
| "If we were aware of the bigger picture of his life or had doubts about her, we would of course have acted differently. | |
| "We want to see changes where schools are aware of concerns from other agencies which affect our pupils." | |
| No-one disciplined | No-one disciplined |
| Sharon Binyon, medical director of the Coventry and Warwickshire Partnership NHS Trust said the service as a whole did not do enough. | Sharon Binyon, medical director of the Coventry and Warwickshire Partnership NHS Trust said the service as a whole did not do enough. |
| "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. | "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. |
| "Since the time of Daniel's death the number of health visitors has now doubled and we expect to see it trebled by 2015." | "Since the time of Daniel's death the number of health visitors has now doubled and we expect to see it trebled by 2015." |
| Ms Binyon added no-one had been disciplined following Daniel's death. | 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. | 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. | "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." | "Processes were followed correctly much of the time but processes alone do not save children." |