Transcript The Local Safeguarding Children’s Board
Berkshire West LSCB’s
DANIEL PELKA
:
HIS LEGACY
Genogram
Family History
Polish immigrants 2005
Daniel born in 2007 – father Mr P - left family end 2008
Mother in relationship with Mr K 2008 – mid 2010
Mother in relationship with Mr A 2010 onwards
Adam born 2011
Family Features
All Polish -Catholic religion
English not first language
Domestic abuse
Alcohol misuse
Mother - mental health issues
House moves
Daniel’s life
March 2008 – laceration over eye
Witnesses domestic abuse
July 2010 bruise side of head
Witnesses DV – knives & attempted strangulation of mother
Daniel’s life
Early 2011 – broken arm, multiple bruising
Started school Sept 2011 – issues re obsession with food, attendance, loss of weight.
School noted facial injuries Dec – Feb 2012
Daniel’s life
Ron Lock, Overview Author stated:
“if there were such concerns about
the injuries alongside the background of the other concerns, it is difficult to understand why the school did not coordinate these and ensure that a child protection referral was made to CLYP at the time”. Why do you think this was?
Daniel’s life Paediatric appt Feb 2012 (aged 4 yrs 7 months)
Wet himself
No recognisable words
Weight 13.8kg
Mother’s explanation
Further investigations
Daniel’s secret life after his death discovered
Anna’s involvement
Junk or box room
Withdrawal of food
Use of salt
Being hit
Bath and nearly drowning
Daniel’s death
2 nd March 2012 – not at school. Salt poisoning & not responding – ‘he’ll get over it’
3 rd March – cardiac arrest, emaciated & malnourished, bruising & head injury; died ‘direct blow to head’
Missed opportunities
Antenatal bookings
Child development appts
27 domestic abuse events known to Police
Mother’s hospital attendances
Minor injuries to Anna
Missed opportunities
Injuries to Daniel noticed by school & Paediatrician
Daniel scavenging for food at school – school accepted mother’s explanation
Failure of professionals to check information with each other
Missed opportunities
Assessments by social workers
Males were not visible
Daniel only spoken to on one occasion – issue of him speaking Polish
Professional communication
Impact of moves
Not proactive
Confused & ineffective communication
Assumptions
Lack of multi-agency contributions to social work assessments
Professional communication
Not holistic
Not historic
‘Start again’ approach
Incident focused
Lack of child focus
Lack of mgt oversight
Police Practice Issues
Need to be child centred at all incidents
Broader checks of situation
Always consider the impact of DV on children
Timely notifications to Children’s Services
Health Visitor’s Practice Issues
Lack of communication with GP’s
Lack of robust attempts to complete assessments
Presumption that no DV
Not responsive to notifications of injury nor DV
Hospital Practice Issues
Identification of impact of mother’s OD on children Need to question plausibility of parental explanations Focused on main injury without considering other injuries & issues in context Rationalisation & under responsiveness
Midwifery Practice Issues
No clarification about mother discharging herself Not proactive when missed 4 antenatal appointments Not proactive when mother disclosed DV – inappropriate view that DV is not child protection concern
GP Practice Issues
Failure to alert other professionals
Adult focus
Lack of proactive responses
Need to record on adult & child records
Probation’s Practice Issues
Failed to up-date assessment when Mr A returned to home – ‘no realistic protection’
Curfew arrangements
Risk assessments
Adult focus
Children’s Services Practice Issues
Poor quality assessments
Lack of male inclusion
Disguised compliance
Did not talk directly to Daniel or Anna
School’s Practice Issues
Disguised compliance
Use of interpreters
Disparity of views
No effective coordination with school nurses or each other
Poor recording systems
Consolidating & improving practice
Take every opportunity
Robustly challenge explanations & reassurances from parents
Domestic abuse is always a child protection issue
Talk directly to children – ensure no child is invisible
Consolidating & improving practice
Develop understanding of patterns
Write effective and timely records and reports
Physical injuries, especially to face must always be considered as abuse
Consolidating & improving practice
Consider impact of family’s circumstances
Hold own professional judgements
Assess evidence re: ability / willingness to change
Consolidating & improving practice
Don’t rely on family members to corroborate
Don’t make assumptions without checking with colleagues
Always consider child abuse as potential cause
Retain healthy scepticism
Daniel’s mother & her partner, Mr A, were charged with Daniel’s murder and received sentences of 30 years imprisonment in July 2013.