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The review said professionals who came into contact with Daniel missed chances to help him
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.
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".
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'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).
Case Analysis
Four-year-old Daniel Pelka was an isolated child with little English who, according to the serious case review, must have existed in a state of anxiety and stress.
Part of the tragedy is that many professionals, from police to teachers to doctors and social workers, were involved with the family, but the report says none actually had a conversation with Daniel about what his life was like.
That lack of focus on the child, along with professionals who too readily accepted what his deceitful mother said and who didn't share information, is a sadly familiar pattern of failures in difficult child protection cases.
The report says it's disconcerting that many of the lessons to be learned from what happened in Coventry, reflect what has already been found in other abuse cases nationally. Its message is that to really protect children, professionals have to think the unthinkable.
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:
- Police were called to 26 separate incidents at the family home, many involving domestic violence and alcohol abuse.
- Excuses made by Daniel's "controlling" mother were accepted by agencies.
- Professionals needed to "think the unthinkable" and act upon what they saw, rather than accept "parental versions".
- Daniel's "voice was not heard" because English was not his first language and he lacked confidence.
- No record of "any conversation" held with Daniel about his home life, his experiences outside school, or of his relationships with his siblings, mother and her partners.
- None of the agencies involved could have predicted Daniel's death.
- There were "committed attempts" by his school and health workers to address his "health and behavioural issues" in the months before his death.
- But "too many opportunities were missed for more urgent and purposeful interventions".
- Two of those chances were when Daniel was taken to an accident and emergency department with injuries.
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.
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Amy Weir, chair of the Coventry Safeguarding Children Board, says the report is "disheartening and generally worrying"
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".
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.
Mr Timpson said he had written to the Coventry Safeguarding Children Board asking for a clearer analysis as to why the mistakes occurred.
'Invisible' DanielAmy Weir, the board's chair, said she found the report "disheartening, disappointing and generally worrying".
Pelka Serious Case Review
- An independent review set up after Daniel's death in March.
- Chaired by Dr Neil Fraser, a paediatrician from outside Coventry.
- Carried out by a panel including a Det Ch Insp from the Public Protection Unit, West Midlands Police, and a manager from the NSPCC.
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.
"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."
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.
"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.
"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 disciplinedSharon 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.
"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.
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."
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