COVENTRY HANG YOUR HEADS IN SHAME

http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf


Coventry Safeguarding
Children Board
Serious Case Review
Re Daniel Pelka
Born 15th July 2007
Died 3
rd March 2012
Overview Report
Independent Serious Case Review Panel Chair – Dr Neil Fraser
Independent Overview Report Author – Ron Lock
September 2013 – Final Publication CopyCoventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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CONTENTS
Introduction 1-1 – 1-6 Page 3
Brief Summary of the Case and Findings from the SCR 2-1- 2-7 Page 5
The Serious Case Review (SCR) Process 3-1 – 3-8 Page 7
Genogram Page 12
Factual Information 4-1 – 4-88 Page 13
The Children’s Experience 5-1 – 5-17 Page 30
Analysis of Professional Practice
-Assessment, intervention and decision making 6-1 – 6-9 Page 35
-Response to domestic abuse 6-10 – 6-26 Page 37
-Response to Daniel’s fractured arm 6-27 – 6-33 Page 41
-The response to concerns about Neglect and Health 6-34 – 6-38 Page 45
-Assessment and decision making 6-39 – 6-49 Page 46
-Knowledge of and response to adults in the home 6-50 – 6-58 Page 49
-Sensitivity to the needs of the children 6-59 – 6-65 Page 52
Events leading up to Daniel’s death
-School concerns about Daniel 7-1 – 7-9 Page 54
-The Paediatric Assessment 7-10 – 7-16 Page 57
-Injuries to Daniel noticed by school staff 7-17 – 7-18 Page 59
- Summary 7-19 – 7-20 Page 60
Professional communication, information sharing and liaison in respect of service delivery,
including between those working out of hours and across borders
Professional communication 8-1 – 8-10 Page 61
Practitioners knowledge about abuse and neglect 9-1 – 9-3 Page 63
Sensitivity to race culture, linguistics & religion 10-1 – 10-8 Page 64
Management oversight 11-1 – 11-2 Page 66
Consistent with policy and procedures 12-1 – 12-2 Page 67
Organisational factors 13-1 – 13-3 Page 67
__________________________
Summary of findings 14-1 – 14-9 Page 69
Lessons Learned 15-1 – 15-14 Page 72
Overview Report Recommendations 16-1 – 16-15 Page 74
___________________________
Appendix 1 – Biographies of Independent chair and author
Appendix 2 – Domestic abuse incidents
Appendix 3 – Individual Management Review RecommendationsCoventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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1. Introduction
1.1 This Serious Case Review (SCR) was commissioned following the death of Daniel Pelka, the
middle child of a family who had migrated to this country in 2005 from Poland and who lived
in Coventry for most of the time that they resided in the UK. Daniel was 4 years 8 months old
at the time of his death on the 3rd March 2012, and he had an older sibling, who will be
referred to as Anna in this report, and a younger sibling, who will be referred to as Adam, who
were aged approximately 7 years and 1 year respectively at the time of their brother’s death.
(Please note their names have been changed to protect their identity and the gender used in
this report may not accurately reflect their actual gender). At that time the family comprised
of the children’s mother, Ms Magdalena Luczak, and the father of Adam, Mr Mariusz Krezolek.
1.2 The circumstances of Daniel’s death suggested that he had been suffering abuse and neglect
over a prolonged period of time. He was found to be malnourished at the time of his death
and also had an acute subdural haematoma1
to the right side of his head, as well as other
bruises on his body. Subsequent pathological examination also identified older mild subdural
haematoma of several months or years duration. Ms Luczak and Mr Krezolek were charged
with murder, and evidence presented at their criminal trial gave details of the neglect and
physical abuse that Daniel suffered and that he had for periods of time been locked in a
sparsely furnished room in the home as a form of punishment. The adults were found guilty
of these charges on 31st July 2013.
1.3 If “abuse or neglect is known or suspected to be a factor in the death” of a child, this requires
that the Local Safeguarding Children Board (LSCB) should “always conduct a SCR into the
involvement of organisations and professionals in the lives of the children and the family”2
,
and therefore in response to this guidance, Coventry LSCB commissioned a SCR following
Daniel’s tragic death.
1.4 The purposes of this Serious Case Review reflected the relevant government guidance at the
time to: -
- Establish what lessons are to be learned from the case about the way in which local
professionals and organisations work individually and together to safeguard and promote the
welfare of children;
- Identify clearly what those lessons are both within and between agencies, how and within
what timescales they will be acted on, and what is expected to change as a result; and
1
“A subdural haematoma is a collection of blood on the brain and are usually the result of a serious head
injury. When one occurs in this way it is referred to as “acute” and is among the most serious of all head
injuries. The bleeding fills the brain area very rapidly, compressing brain tissue This often results in brain
injury and may lead to death” National Library of Medicine – July 2012.
2
Paragraph 8.9 – Working Together to Safeguard Children – A guide to inter agency working to safeguard and
promote the welfare of children – Dept. for Children, Schools and Families – March 2010 (NB: This guidance
was reissued in March 2013 after completion of much of this SCR although very similar criteria for conducting a
SCR is included)Coventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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- Improve intra and inter-agency working to better safeguard and promote the welfare of
children.3
1.5 In order to undertake the SCR effectively and to ensure that the agencies in Coventry were
able to individually and collectively learn any relevant lessons in respect of safeguarding
children, each agency that had some direct involvement with Daniel and his family was
required to undertake an Individual Management Review (IMR) to look openly and critically at
its practice in relation to their involvement with the family. In undertaking this, each agency
was also required to produce a chronology of its contact with the family. The
managers/officers conducting the IMRs did not at the time immediately line-manage the
practitioners involved and were not directly concerned with the services provided for the
children or the family.
1.6 Senior representatives from relevant organisations in Coventry were brought together to form
a SCR Panel in order to review and analyse the material from the IMRs and other information
presented to the panel. This took place over a number of meetings for a period of
approximately six months. Because the criminal proceedings had not been completed by this
time, it was not possible to finalise the SCR process or consider publication of the Overview
Report at that time. Dr Neil Fraser, an experienced paediatrician from outside Coventry, was
commissioned to be the independent chair of the SCR, and Ron Lock, an independent
safeguarding consultant with extensive professional experience in safeguarding children and
young people, was commissioned to detail the analysis and findings from this SCR and
complete the Overview Report. (Short biographies are attached at Appendix 1)
3
Paragraph 8.5, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March
2010Coventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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2. Brief Summary of the Case and Findings from the SCR
2.1 Daniel was murdered by his mother and stepfather in March 2012. For a period of at least six
months prior to this, he had been starved, assaulted, neglected and abused. His older sister
Anna was expected to explain away his injuries as accidental. His mother and stepfather acted
together to inflict pain and suffering on him and were convicted of murder in August 2013,
both sentenced to 30 years' imprisonment.
2.2 Daniel's mother had relationships with 3 different partners whilst living in the UK. All of
these relationships involved high consumption of alcohol and domestic abuse. The Police
were called to the address on many occasions and in total there were 27 reported incidents of
domestic abuse.
2.3 Daniel's arm was broken at the beginning of 2011 and abuse was suspected but the medical
evidence was inconclusive. A social worker carried out an assessment but no continuing need
for intervention was identified.
2.4 In September 2011, Daniel commenced school. He spoke very little English and was
generally seen as isolated though he was well behaved and joined in activities. As his time in
school progressed, he began to present as always being hungry and took food at every
opportunity, sometimes scavenging in bins. His mother was spoken to but told staff that he
had health problems. As Daniel grew thinner his teachers became increasingly worried and
along with the school nurse, help was sought from the GP and the community paediatrician.
2.5 Daniel also came to school with bruises and unexplained marks on him. Whilst these injuries
were seen by different school staff members, these were not recorded nor were they linked to
Daniel’s concerning behaviours regarding food. No onward referrals were made in respect of
these injuries. At times, Daniel’s school attendance was poor and an education welfare
officer was involved.
2.6 Daniel was seen in February 2012 by a community paediatrician, but his behaviours regarding
food and low weight were linked to a likely medical condition. The potential for emotional
abuse or neglect as possible causes was not considered when the circumstances required it.
The paediatrician was unaware of the physical injuries that the school had witnessed.
2.7 Three weeks after the paediatric assessment Daniel died following a head injury. He was thin
and gaunt. Overall, there had been a rapid deterioration in his circumstances and physical
state during the last 6 months of his life.Coventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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Findings
 Daniel's mother and stepfather set out to deliberately harm him and to mislead and deceive
professionals about what they were doing. They also involved Daniel’s sister Anna in their
web of lies and primed her to explain his injuries as accidental.
 A pattern of domestic abuse and violence, alongside excessive alcohol use by Ms Luczak and
her male partners, continued for much of the period of time from November 2006 onwards,
and despite interventions by the Police and Children’s Social Care, this pattern of behaviour
changed little, with the child protection risks to the children in this volatile household not
fully perceived or identified.
 Missed opportunities to protect Daniel and potentially uncover the abuse he was suffering
occurred:-
o at the time of his broken arm in January 2011, which was too readily accepted by
professionals as accidentally caused,
o when the school began to see a pattern of injuries and marks on Daniel during the
four months prior to his death, and these were not acted upon, and
o at the paediatric appointment in February 2012 when Daniel’s weight loss was not
recognised, and child abuse was not considered as a likely differential diagnosis for
Daniel’s presenting problems.
 At times, Daniel appeared to have been "invisible" as a needy child against the backdrop of
his mother's controlling behaviour. His poor language skills and isolated situation meant
that there was often a lack of a child focus to interventions by professionals.
 In this case, professionals needed to “think the unthinkable” and to believe and act upon
what they saw in front of them, rather than accept parental versions of what was happening
at home without robust challenge. Much of the detail which emerged from later witness
statements and the criminal trial about the level of abuse which Daniel suffered was
completely unknown to the professionals who were in contact with the family at the time.
 A number of critical, significant lessons have been identified by this SCR, which are detailed
later, and it is now of utmost importance that they are translated into action by front line
professionals and adopted for inclusion within relevant child protection processes and
systems and as part of the support and supervision that these professionals require in their
day to day work with vulnerable children.Coventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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3. The Serious Case Review (SCR) Process
3.1 Time Period
The time period covered for this SCR was from the earliest contacts with the family in 2005, which
was the year in which members of the family arrived in the UK from Poland, until the death of Daniel
in early March 2012.
3.2 Agencies required to provide Individual Management Reviews (IMRs)
- Coventry and Warwickshire NHS Partnership Trust
- University Hospitals Coventry and Warwickshire NHS Trust
- Coventry City Council - Children, Learning and Young People Directorate (CLYP)
- NHS Coventry/NHS Warwickshire
- West Midlands Police
Additional information was provided to the SCR Panel by the Community Services Directorate of
Coventry City Council, Bedworth Children’s Social Care, Warwickshire, and the Staffordshire and
West Midlands Probation Trust.
3.3 The Serious Case Review Panel
Dr Neil Fraser – Paediatrician and Independent Chair
- Interim Business Manager – Coventry Safeguarding Children Board
- Senior Manager SEN, Education and Learning – CLYP - Coventry
- Head of Safeguarding – Children’s Safeguarding Service - Coventry
- Named Dr, Child Protection, UHCW (University Hospital Coventry & Warwickshire NHS Trust)
- NSPCC Manager & Chair of Coventry LSCB Serious Case Review Sub Committee
- Detective Chief Inspector – Public Protection Unit, West Midlands Police
- Head of Service, Social Work and Family Intervention - CLYP, Coventry City Council
Also in Attendance
- Ron Lock – Independent Overview Report Author
- Legal Officer, Coventry City Council - Legal Advisor to the LSCB and to the SCR Panel.
3.4 Independence
3.4.1 All authors of the IMRs were independent of the services delivered to the family and
the details of their independence were clarified in each of the IMRs.
3.4.2 Dr Neil Fraser provided the role of independent chair of the SCR Panel and had no
previous knowledge or direct involvement with the family who were subject to the review.
He was also able to provide specialist contributions to the analysis of paediatric assessment
in this case.
3.4.3 The overview report writer was independent of all professional agencies in Coventry
and had no previous involvement in a professional capacity with safeguarding practice in the
West Midlands. His background as an independent safeguarding consultant has included
involvement in numerous SCRs either as author or chair. Coventry LSCB – Final Overview Report of Serious Case Review re Daniel Pelka - September 2013
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3.4.4 There was some additional independence via a consultant who specialised in
primary education and safeguarding, who provided additional analysis of this aspect of
professional intervention for consideration by the overview author.
3.5 Specific Issues for the SCR to consider.

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