berkshire west lscb’s daniel pelka : his legacy. genogram

Berkshire West LSCB’s

DANIEL PELKA:

HIS LEGACY

Genogram

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 History

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 - discovered after his death

Anna’s involvement Junk or box roomWithdrawal of foodUse of saltBeing hitBath and nearly drowning

Daniel’s death

2nd March 2012 – not at school. Salt poisoning & not responding – ‘he’ll get over it’

3rd March – cardiac arrest, emaciated & malnourished, bruising & head injury; died ‘direct blow to head’

Missed opportunities

Antenatal bookingsChild development appts27 domestic abuse events

known to PoliceMother’s hospital

attendances Minor injuries to Anna

Missed opportunities Injuries to Daniel noticed

by school & PaediatricianDaniel 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 visibleDaniel only spoken to on

one occasion – issue of him speaking Polish

Professional communication

Impact of movesNot proactiveConfused & ineffective

communicationAssumptionsLack of multi-agency

contributions to social work assessments

Professional communication

Not holisticNot historic ‘Start again’ approach Incident focusedLack of child focusLack 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 DVNot 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 focusLack of proactive

responsesNeed 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 arrangementsRisk assessmentsAdult focus

Children’s Services Practice Issues

Poor quality assessmentsLack of male inclusionDisguised complianceDid not talk directly to

Daniel or Anna

School’s Practice Issues

Disguised complianceUse of interpretersDisparity of viewsNo effective coordination

with school nurses or each other

Poor recording systems

Consolidating & improving practice

Take every opportunityRobustly 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.