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Coventry LSCB publish Serious Case Review

Coventry LSCB published the serious case review into the death of Daniel Pelka today, 17th September 2013. Daniel died in March 2012 from a blow to the head. His death followed months of physical and emotional abuse, including starvation, at the hands of his mother and step-father. The review identified that although the first initial assessment, following domestic violence concerns, was of high quality, three later assessments, including a core assessment following a fracture to Daniel's arm, were dominated by 'the rule of optimism'. Although no single professional could have predicted Daniel's death, numerous opportunities were missed to investigate and challenge what life was really like for the child and his siblings.

Children’s Minister, Edward Timpson, has written to Coventry Safeguarding Children Board asking them to undertake a deeper analysis into why four social care assessments failed to pick up on the risks posed to murdered schoolboy Daniel Pelka.

Other professionals that should have safeguarded Daniel were also criticised, including his school for failing to act when the four-year-old presented with a succession of unexplained injuries. Health visitors should also have followed up domestic violence concerns and missed child health checks more rigorously, the review found. However many of the failings were about applying procedures rather than the lack of them or any particular gaps in service. The report noted some of this could be attributed to a severe shortage of health visitors in the Coventry area and high caseloads amongst the social work team.

Jo Cleary, chair of the College of Social Work, said three significant themes arise from the review, which social workers and other professionals should read "very carefully":

  • domestic violence and alcohol misuse by parents must always be taken seriously as a potential child protection issue;
  • professionals need to be ever mindful of the potential for some parents to deceive and manipulate them;
  • everyone involved in working with children must be unrelenting in their focus on the child and their needs and on making sure that children's voices are heard

  • The report is available on http://www.coventrylscb.org.uk/


    Tues 17th Sept 2013