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Serious case review re Daniel Pelka: born 15th July 2007 died 3rd March 2012: overview report
- Author:
- LOCK Ron
- Publisher:
- Coventry Safeguarding Children Board
- Publication year:
- 2013
- Pagination:
- 76
- Place of publication:
- Coventry
This Serious Case Review (SCR) was commissioned following the death of Daniel Pelka, the middle child of a family who had migrated to this country in 2005 from Poland and who lived in Coventry for most of the time that they resided in the UK. Daniel was 4 years 8 months old when he died on 3rd March 2012,. He had an older sister and a younger brother, aged approximately 7 years and 1 year respectively at the time of their brother’s death. Daniel was murdered by his mother and stepfather in March 2012. For at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister 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 were sentenced to 30 years' imprisonment. This report documents analysis of professional practice in responding to domestic abuse in the household, concerns about neglect and health, and to the child's injuries. The report documents the events leading up to Daniel's death, including school concerns and injuries noticed by school staff. The findings note opportunities missed to protect Daniel and to potentially uncover the abuse he was suffering: he appeared to have been "invisible" as a needy child. The professionals needed to “think the unthinkable”, and to believe and act upon what they saw in front of them, rather than accept without robust challenge, parental versions of what was happening at home. The report highlights a “Start Again Syndrome” (involving changes of address and the children starting a new school), which led this SCR to question professional communication, information sharing and liaison over service delivery (including that between those working out of hours and across borders). It questions the extent to which practitioners were knowledgeable both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child’s welfare. It asks whether the work in this case was consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards (including the involvement of senior managers). Overall, this case raises particular questions about the ability of the different agencies to address domestic abuse, and whether they could have prevented the abuse to and death of Daniel, had they had more enquiring minds. However, the SCR concludes that "it would be too simplistic to identify failings by individual practitioners as the reasons why Daniel was not protected". The report recommends that there must be a review of the systems which currently exist for the notification and sharing of information in respect of domestic abuse incidents within families to ensure that they generate effective outcomes in relation to the safeguarding of children. The review must focus on: the timeliness of notifications; the agency to which they should be distributed, including schools, the importance of a focus on the needs and safety of the children, the efficiency and effectiveness of the joint screening processes and the responsibility for agreed outcomes, and how repeat domestic abuse incidents need to be responded to more holistically. The LSCB needs to demonstrate a clear cohesive understanding of the scope of early help and prevention work to support children living with domestic abuse. Appendix 2 lists the main domestic abuse incidents reported to the police, whether they made any referrals, and what, if anything, they noticed about the children. (Edited publisher abstract)
Serious case review: redacted overview report re SCR 0310
- Author:
- LOCK Ron
- Publisher:
- Gloucestershire Safeguarding Children Board
- Publication year:
- 2011
- Pagination:
- 44p.
- Place of publication:
- Gloucester
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother was prosecuted and found guilty of one count of cruelty, for which she received a two year custodial sentence. Rachel and her older siblings were all from outside of the UK and moved to this country a few months before the serious injury to Rachel occurred. At that time, none of the family could speak English and the mother was a single parent. The older children were all of school age at the time of Rachel’s injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra and inter-agency working to better safeguard and promote the welfare of children.
Serious case review: executive summary: re SCR 0310 September 2011
- Author:
- LOCK Ron
- Publisher:
- Gloucestershire Safeguarding Children Board
- Publication year:
- 2011
- Pagination:
- 16p.
- Place of publication:
- Gloucester
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother was prosecuted and found guilty of one count of cruelty, for which she received a two year custodial sentence. Rachel and her older siblings were all from outside of the UK and moved to this country a few months before the serious injury to Rachel occurred. At that time, none of the family could speak English and the mother was a single parent. The older children were all of school age at the time of Rachel’s injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra and inter-agency working to better safeguard and promote the welfare of children.
Serious case review (Child A): executive summary
- Author:
- LOCK Ron
- Publisher:
- Cambridgeshire Local Safeguarding Children Board
- Publication year:
- 2009
- Pagination:
- 6p.
- Place of publication:
- St. Ives
This Executive Summary reflects the findings from a Serious Case Review which was undertaken to consider the professional involvement of a range of agencies with a family of mother, father and two children who were both under 5 years of age at the time of the family’s arrival in Cambridgeshire approximately 3 years ago. Two further children were later born to the family, although the youngest child tragically died when just a few days old in early 2008. At the time there were professional concerns regarding the cause of the baby’s death. The purpose of the Review was to identify and recommend any relevant changes to professional practice, and to improve the ways in which the different agencies in Cambridgeshire work together to safeguard children and young people.
Serious case review: subject Child born 2006 died 2011: executive summary of overview report
- Authors:
- SCHOFIELD Felicity, LOCK Ron
- Publisher:
- Peterborough Safeguarding Children Board
- Publication year:
- 2011
- Pagination:
- 15p.
- Place of publication:
- Peterborough
A Serious Case Review was commissioned in recognition that a case involving a 5 year old boy who died as a result of an incident at home met the criteria for such a review, in that abuse or neglect was known or suspected to be a factor in the death. The Serious Case Review panel reviewed and analysed submissions from agencies which had some direct involvement with the child and family: Peterborough Children's Services, Peterborough and Stamford NHS Foundation Trust, Peterborough Community Services, general practice, Cambridgeshire Constabulary, and Cambridgeshire and Peterborough Probation Trust. This executive summary covers the serious case process and outlines key events and factual information, key findings and priorities for learning and change.
Serious case review: the Anderson family: overview report
- Authors:
- LOCK Ron, SUFFOLK SAFEGUARDING CHILDREN BOARD
- Publisher:
- Suffolk Safeguarding Children Board
- Publication year:
- 2014
- Pagination:
- 48
- Place of publication:
- Ipswich
This Serious Case Review examined how public agencies worked with Fiona Anderson and her three children, Levina, Addy and Kyden prior to their deaths on 15 April 2013 in Lowestoft. It outlines the facts of the case since June 2009 and the children’s experience. Suffolk County Council Children and Young People Services (CYPS) first started working with Fiona and her partner some 3 years ago, due to concerns about parenting abilities. Court proceedings to remove Levina were commenced; but were withdrawn following challenge, and because at the time there was insufficient evidence. The report acknowledges that this action resulted in the relationship between the family and children’s social care becoming strained from the outset. It identifies that by June 2010, when Levina was aged 12 months, the concerns had diminished sufficiently for formal involvement to cease. Following further concerns, intervention recommenced in August 2011; and Levina and Addy were made subject of Child Protection Plans under the category of ‘neglect’. When Kyden was born in May 2012 he was included in the Plan. The report acknowledges that the child protection process was implemented in line with recognised procedures. However, it was inappropriate for the Child Protection Plans to continue largely unchanged for a period of eighteen months from August 2011 without some form of review and formal revision with the family. The lack of progress was not challenged by managers or other professionals. The SCR analyses the legal strategy and child protection plans; physical and emotional neglect; working with a hard to reach, avoidant family; the impact of work with a complex family; maternal mental health; and organisational factors. Among the 13 lessons learned is that using innovative multi-agency interventions is required when working with hard to reach and avoidant families. Also required is a focus on the children’s experiences to identify whether there is emotional abuse or neglect in a family, otherwise children will be at risk if child protection plans are not continually acted upon. The pivotal role of the child protection conference (CPC) Chair in challenging the management of a case is acknowledged, coupled with managers’ and specialists’ involvement, as well as those professionals directly involved with families. All professionals have responsibility for challenging inappropriate or ineffectual practice; for there to be robust management oversight when dealing with demanding child protection cases; and the importance of having a record of important discussions and agreements. When there are concerns about a parent’s possible mental health problems, a relevant assessment will need to be made, even if the parent does not see the need. The predominant feature of this case was the challenge of how to engage with a hard to reach family, and especially the mother who specifically avoided professional interventions. However, a Public Law Outline (PLO) process or an application for Care Proceedings was never tested. (Edited publisher abstract)