Health Services Learn from Daniel Pelka Serious Case Review

Published: February, 2014

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Daniel Pelka 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.
Following publication of the serious case review into the death of Daniel Pelka, a deeper analysis of the reasons why practice
failures had occurred has taken place. Questions answered include:

-Why was basic information not recorded properly both within and between agencies?
-Why was information needed to protect Daniel not shared between the relevant agencies?
-Why did four separate assessments by children’s social care all fail to identify the risk to Daniel?
-Why wasn't the high risk identified by Signs of Safety approach acted on?
 My proposal is that in analysing our health services reponse we also look at the theory behind the Systemic Units Approach being used by Child Protection Teams in Hackney.
A copy of the deep analysis response to the serious case review is available on line- click here
A copy of the Serious Case Review Overview Report  - click here
Documents describing the Systemic Units approach now used by the child protection team in Hackney are attached at the bottom of this page

Health Related Issues raised and discussed in the deep analysis (response to the SCR)  are  in red font..... below the red font text and  in italics you will find a summary of Daniel's situation.

 From the Young Persons Guide to Working Together 2013

'The Children’s Rights Director asked children and young people what they thought

health visitors should do to help keep them safe. They said:

• chat to parents –build up a relationship with them;

• communicate with social workers;

• call round out of the blue;

• look round the house; and

• look in the fridge and cupboards.


The Children’s Rights Director asked children and young people what they thought

doctors should do to help keep them safe. They said:

• tell people if you’re concerned; and

• do more home visits to see what the home is like.'



There are three key points in time identified as having had the potential to change outcomes for Daniel - each has an interdependence with health services and there are many lessons that all of us can learn from.

-at the time of Daniel's 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’  presenting problems.

 Health Related Issues raised and discussed in the deep analysis (response to the SCR)

- There were no family records within community health services resulting in a situation where the school nurse and health visitors did not have a full picture of the family circumstances. The lack of a full picture was exacerbated by central allocation of health visitor tasks such as developmental checks or new birth visits, resulting in a lack of consistency in work with the family.

-The fact that there was no expectation within health that children’s height and weight was plotted over time (for example on a centile chart) and a record kept within their file meant that there was no means of the various health professionals having an easily available visual record that compared Daniel’s good progress in his early years with dramatic decline in the year prior to his death.

-Staffing pressures within health visiting, a delay in receiving information from the police and lack of clarity regarding their role resulted in the health visiting service routinely treating domestic violence notifications as ‘for information only’. Health visitors in receipt of information that should have worried them relied on the police assessment and social workers visiting, rather than being proactive and visiting the family themselves.

-The use of language including that it was “plausible” that the spiral fracture to Daniel’s arm was accidental had a disproportionate impact on decision making at the strategy meeting.This is not a criticism of the doctor using the term at that time but point of learning for the future.

-Poor standards of communication relating to problems with information sharing systems between acute hospital trusts and community health services, and the separation of midwifery records from other parts of the system meant that risks relating to mothers mental health and her behaviour whilst pregnant was not known to health visitors or the GP.
Such information would not be available within the parent held records.
This combined with a lack of a family record within health meant that previous concerns about Daniel were not known to the health visitor carrying out a pre birth visit in respect of Adam.

-Information exchange at the point Daniel started school was adversely affected by the reliance on paper records within health visiting, the use of an electronic system within school nursing and term time working arrangements for school nurses.

-Communication between the school nurse and the school was adversely affected by the fact that she was not the usual school nurse for that school and did not know the most appropriate person to speak to. She also did not have the usual informal opportunities to see Daniel within school.

-Insufficient training for staff within the school meant that they were unclear of their role in the child protection process, who to go to with concerns and what to do if their concerns were not heard within the school environment.

-The assessment by the community paediatrician was an opportunity to explore whether abuse was one possible explanation for Daniel’s symptoms. It has not been possible to explore in any detail why this did not happen although the
paediatrician reports that their actions were partly influenced by poorly kept hospital records, no centile charts within
the records and a lack of strategy meeting minutes giving a fuller explanation of the circumstances surrounding Daniel’s fractured arm.

-Assessments within the school failed to bring together all known information and identify risk of abuse due to fragmented information gathering and recording systems within the school. In addition appropriate professional judgement was not used in the decision not to refer Daniel’s situation to Children's Social Care.
The delay in processing domestic violence notifications resulted in health visitors receiving the information some time
after the event and often the documents arriving in batches. An already over-stretched health visiting service viewed
notifications as ‘for information only’ and health visitors mainly relied on the grading given by police officers
to determine whether they should take further action such as visiting the home. A risk assessment grading designed to assess risk to the victim was therefore used by health visitors to decide whether a response was needed in relation to the children. One health visitor commented that when domestic violence notifications first started coming from the police into health, there was no policy guidance as to what to do with them and there was no expectation that domestic violence notifications from the police were for anything other than information. There was no system of these being screened by an experienced health professional, although health visitors could contact their domestic violence lead nurse if they had concerns. Workload pressures affected health visitors’ capacity to process and respond to information and it is clearly the case that during 2008 there was no expectation that families where there was recurrent domestic violence might need to be visited and a CAF considered. It is well documented in letters sent by the Chair of the Safeguarding Children Board to the Primary Care Trust at the time , in mid 2011, that there were concerns that the low level of staffing within the health visiting service was adversely affecting child protection practice.

-The use of language by health professionals in sharing information at the strategy meeting appears to have been significant in the way that their views were interpreted by others. The doctor’s comment that mother’s description of the injury was ‘plausible’ appears to have been a major influence in the decision not to pursue section 47 enquiries
and it would have been more helpful if the doctors had simply stated that both an accidental and non accidental cause were possible. It is likely that this combined with the fact the Anna had corroborated her mother’s account resulted in the
meeting losing sight of the potential significance of the bruising as well as the fracture and the fact that mother had delayed bringing Daniel to hospital. Information about previous domestic violence (including that perpetrated by mother) was brought to the attention of the meeting and the focus shifted from events surrounding the injury to the issue of domestic violence.
Ineffective written communication between acute hospital trusts and community services has been referred to
above. In addition to the communication from the hospital consultant to the GP in relation to Daniels’ broken arm, on two occasions information from the accident and emergency department regarding mother’s overdose and attempt
to run out in front of an ambulance did not reach the health visitor. This would have raised the health visitor ’s
level of concern, prompted a visit and, when domestic violence notifications were received, most likely have resulted in
liaison with children's social care. Social workers may then have been aware of this incident at the time of the first
initial assessment. There is a completed fax form in the health visitor notes from accident and emergency outlining the incident,however, unlike every other document in the health visitor file there is no date stamp indicating when this was received by the surgery. The lack of effective use of the paediatric liaison role is reported to be likely to have exacerbated communication problems and would have been an important addition to a reliance on paper based communication methods.
The period when mother was pregnant with Adam tested the capacity of the health system to link up emerging concerns about one child (the unborn baby) with other children in the family (Daniel and Anna).
Sadly, problems with information sharing within health contributed to information about mother’s pregnancy with Adam
becoming lost at the time of the fracture to Daniel’s arm. Midwifery information was only available to other professionals within the  hospital if requested and the health visitor did not have an overall picture of family circumstances mainly due to the central allocation system within  health visiting.
This system means that when a case becomes inactive it effectively has no health visitor;(although one can always be allocated should issues arise for the parent or other professionals) when next activated it may be allocated to any health
visitor covering that area.
The health visitor who liaised with children's social care after the fracture was not the same one who had visited the family in July 2010 and carried out a developmental check on Daniel and was unaware of the pregnancy.
All of this resulted in a serious lack of consistency in staff dealing with the family which made it much more difficult for a coherent and critical assessment to be made particularly when outwardly the household was clean and tidy and there was obviously food available for the children.
Communication systems between health visiting and school nursing did not facilitate effective exchange of information across the two services . The accumulating concerns in relation to the family as a whole were therefore not recognised as potentially needing either a CAF assessment or, potentially,referral to children's social care.
The reason for this was threefold. Firstly, at the time the health visitor conducted a new birth visit in relation to Adam and mother expressed concerns about Daniel ’s behaviour and eating problems, Daniel was about to start school and all his records were boxed up awaiting transfer from health visiting to school nursing.
Whilst there was a system in place the  health visitor did not identify potential risk to Daniel from the single event that had come to her attention and the system for retrieving records was not used.
Secondly, school nurses work term time only and were not available for a face to face discussion at the time of the new birth visit. Thirdly, communication between the health visitor and school nurse was further hampered by the fact that they do not share the same database/case recording system resulting in delays whilst health visitor paper records are  transferred and scanned into the school nursing records.
Midwifery staff who were concerned about mother’s behaviour on the ward did attempt to find out whether mother was known to police or children's social care, but the response that a core assessment had recently been carried out took the focus away from the current behaviour within the hospital. At the time communication systems between hospital midwifery departments and health visiting services were ineffective. It has not been possible to understand clearly
why this was although it is likely that the severely under resourced health visiting service and lack of time to develop  effective working relationships may have been a contributory factor The impact of ineffective communication was that when the health visitor carried out the new birth visit and mother spoke to her about problems with Daniel, she was  unaware of the incidents that had taken place in the hospital.
The ‘start again’ approach to the new birth visit by the health visitor was further exacerbated by the system of central allocation within health visiting, described above since the health visitor conducting the new birth visit did not know the family. There are no family records and she did not have Daniel’s records as he was starting school the next month and they were already boxed up for the school nurse. The health visitor therefore visited knowing nothing about the previous domestic violence or possible non-accidental injury to Daniel.
Coventry had adopted the signs of safety approach to their work. This should include working openly and honestly with parents and developing plans with the family to keep the child safe. However, because this assessment was not starting from a position of recognising danger to the child there was no such open honest discussion with mother.
Two signs of safety rating scales were completed and recorded within the documentation which indicated high risk, although the final conclusion and outcome did not reflect this and the decision was to refer to Citizens Advice Bureau and close the case. The human tendency to use information that confirms an already formed point of view is well documented in the literature and in this case, despite the social worker recording evidence that indicated a high level of concern, the case was closed.

Brief Summary of the Case  from the SCR
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.

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.
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.
In September 2011, Daniel commenced school. Hespoke 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.

Daniel also came to school with bruises and unexplained marks on him. Whilst these injurieswere 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.

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 causeswas not considered
when the circumstances required it.The paediatrician was unaware of the physical injuries that the school had witnessed.

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.


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:-

-at the time of his broken arm in January 2011, which was too readily accepted by professionalsas 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’  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 wascompletely unknown to the professionals who were in contact with the family at the time

Working Together 2013 states

All providers of NHS funded health services including NHS Trusts, NHS Foundation Trusts and public, voluntary sector, independent sector and social enterprises should identify a named doctor and a named nurse (and a named midwife if the organisation provides maternity services) for safeguarding. In the case of NHS Direct, ambulance trusts
and independent providers, this should be a named professional. GP practices should have a lead and deputy lead for safeguarding, who should work closely with named GPs. Named professionals have a key role in promoting good professional practice within their organisation, providing advice and expertise for fellow professionals, and ensuring
safeguarding training is in place. They should work closely with their organisation’s safeguarding lead, designated professionals and the LSCB.
NHS organisations are subject to the section 11 duties set out in paragraph 4 of this chapter.Health professionals are in a
strong position to identify welfare needs or safeguarding concerns regarding individual children and, where
appropriate, provide support. This includes understanding risk factors, communicating effectively with children and families, liaising with other agencies, assessing needs and capacity, responding to those needs and contributing to multi
-agency assessments and reviews. A wide range of health professionals have a critical role to play in safeguarding
and promoting the welfare of children including: GPs, primary care professionals, paediatricians, nurses,health visitors, midwives, school nurses,those working in maternity, child and adolescent mental health, adult mental health, alcohol and drug services, unscheduled and emergency care settings and secondary and tertiary care.
All staff working in healthcare settings including those who predominantly treat adults should receive training to ensure they attain the competences appropriate to their role and follow the relevant professional guidance
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