JimKenJim Kennedy analyses the serious case review on the circumstances surrounding the death of Daniel Pelka.

Before going further with this briefing, I have to confess that I have not had the stomach (or the time) to review all the press coverage on the serious case review. But the heading in the Times was: ‘Daniel tortured and killed after repeated social work blunders’.

And the more detailed report immediately then says that ‘Children’s Services wrongly concluded on four separate occasions that Daniel was safe at home…after conducting supposedly rigorous child care assessments…’

Having read the serious case review, I don’t think anyone will be able to suggest that social workers or the Children’s Department (called the Children, Learning and Young People Directorate – CLYP – in Coventry) come out of the account well. But to imply that theirs was overwhelmingly the main, only and/or most direct fault, seems to me to take an unbalanced view of the reported circumstances.

I make this point because the bulk of the contact with CLYP referred to came at earlier stages in Daniel’s life. Having read about the circumstances at that time, there are undoubtedly questions about the way the Department behaved. But the notion that the evidence at that stage would have been sufficient to enable compulsory protective measures to be taken seems an uncertain one.

That is not to say that much more could been done to offer support to the family and to more directly assess and engage with the children themselves.

The other key issue that is missed, by conflating information about assessment processes in this way, is that some of the earlier assessments involved other partners of Daniel’s mother – that is, not the man who eventually participated in his murder.

Given what is known about the potentially fatal impact of new (mostly male) partners in cases of serious abuse, it would be a pity if this crucial fact was missed in any practice reflections on this case.

Many readers of the British Journal of Family Medicine will have to read the Review to see the detail of the family events that surrounded Daniel’s early life. There is an excellent and detailed chronology of all that unfolded, but a further point that struck me as I read through the account is that there was a hard-to-believe series of interactions with relevant agencies, including the police, over those chaotic early years.

Nevertheless, the focus of those contacts was overwhelmingly on instances of domestic abuse, alcohol misuse, maternal mental ill health, and financial and practical difficulties. Very few of those interventions arose from direct concerns about the children, including Daniel. And, as noted, much of it occurred when the mother was in relationships with men other than the one who killed Daniel.

That’s not to say that the cumulative effects of those incidents and the known connection of those circumstances to heightened risk of child abuse should not have triggered more urgent action; nor – most importantly – is to excuse the fact that throughout there is little evidence of direct or private contact between the professionals concerned and the children themselves.
It’s just that it wasn’t until much later that direct evidence of harm to Daniel began to emerge; and that fact should be borne in mind when considering the practice implications of the case.

As far as I can see, for instance, there was no subsequent referral (until the very end) to children’s services after the period when Daniel’s arm was broken, with concerns over the remaining period of Daniel’s life centring on school, education welfare officers and paediatric involvement. It’s also that the precise facts of the case after Daniel suffered a broken arm are more complicated to assess because of evidence that emerged at the murder trial.
And much has been made in the press about Daniel’s low body weight and reported hunger at school. It may be important to note that the Review points out that Daniel did not die of starvation – the cause of death was a head injury – and, although a serious concern, if Daniel had survived his nutrition and low weight could have been successfully addressed.

Turning now to criticism of the role of Children’s Services, there is no doubt that the Review points to serious deficiencies in the practice of the Department, concluding that:

“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.”

And, I have to say, that reading the detailed chronology begs a number of serious questions about the speed and rigour with which Children’s Services responded to concerns raised. Some of those instances may reflect inaccurate recording of events and communications, in other agencies, but, overall, the account gives a worrying impression of some of the practice pursued by the Department.

But it’s important to note that the main findings of the Review also say that:
“Missed opportunities to protect Daniel and potentially uncover the abuse he was suffering occurred:

• at the time of his broken arm in January 2011, which was too readily accepted by professionals as accidentally caused,
• 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
• 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.”

In summary, it seems to me that the key practice lessons that emerge from an initial reading of the Review focus on:

• the need to take full account of the possible child-risk implications of domestic, and alcohol abuse – particularly where there is a sustained pattern of such concerns over a period of time
• the need to take account of the role of new and changing partners, particularly men, in vulnerable families
• the need to ensure that cumulative evidence is taken into account, rather than allowing a focus on single incidents to develop
• the need not to accept parental explanations for injuries or ill-health at face value and to pursue proper assessment, even if that risks confrontation
• the overwhelming need to ensure that children are seen and are seen alone
• and that if language or communication issues make that difficult, the need to overcome them
• the need, whenever there is concern about a child, to see their accommodation and the room they sleep in
• the need to consider building relationships with, and talking to older siblings, to gain a proper understanding of their views and experiences

None of these lessons are new. They are almost all covered in our earlier Special Report on the cumulative lessons learned from serious case reviews, and published in 2009. Whether Daniel’s death was preventable or not, and whether social services or other agencies played a more important role in events, are important but ultimately impossible-to-resolve questions.

But what a sadness it is to read, once again, of the terrible death of a child. And how depressing it is, to have to reflect, once again, on a child’s death where I simply cannot say to my family and friends that the basics were done, and done well.


Jim Kennedy is editor of CareKnowledge, an online knowledge portal for social workers and directors of social care.