Agencies missed many chances to tackle abuse

A serious case review into the death of Daniel Pelka found repeated failures by the agencies set up to safeguard children’s welfare but concluded nobody could have predicted his death.

The review found his controlling mother Magdelena Luczak and stepfather, brutal former soldier Mariusz Krezolek, spun a “web of lies” to conceal systematic abuse of the boy, from Coventry, who died of a head injury in March last year.

The report also revealed for the first time, through 27 separate police logs between 2006 and 2011, how Daniel grew up in a household dominated by routine violence and alcohol abuse.

Luczak and Krezolek, both originally from Poland, were convicted of the youngster’s murder and are now each serving a minimum of 30 years behind bars.

During their trial at Birmingham Crown Court, the jury heard how Daniel had been kept locked in a box room as a virtual prisoner, fed salt, and routinely beaten.

The serious case review concluded several critical opportunities were missed to intervene.

There was too much reliance in accepting Luczak and Krezolek’s version of events, with the report concluding health staff and social workers could instead have dared to “think the unthinkable”.

The review by Coventry Safeguarding Children Board has published 15 recommendations aimed at preventing such a failure happening again.

These include calls for greater communication between the different child protection agencies, and a strengthening of working procedures and staff training.

The board said there was “inconsistency” when referrals were made by the police and how they were dealt with.

It also looked at several missed opportunities by child welfare agencies to intervene, including when he was brought in to A&E with a broken arm caused, his mother and stepfather falsely claimed, when he jumped off a sofa at home.

The safeguarding board reflected that at no point was Daniel spoken to on his own by social services about his home life.

The review also pointed to the last six months of Daniel’s life when there were “a number of missed or delayed opportunities to intervene more effectively to assess and respond to the mounting concerns about Daniel’s behaviours, physical injuries, lack of growth and weight loss”.

At his primary school, teaching staff noticed Daniel was “wasting away” and had been caught stealing food from other children’s lunch boxes or stealing scraps from the bins – but his behaviour was put down to a medical condition rather than child abuse.

The serious case review report read: “The significance of his condition and of his deterioration was not as evident to the health workers, and school staff did not collectively and purposefully generate their concerns into a coherent child protection referral.

“With the background of mounting concerns by the school about Daniel’s obsession to seek out food, as well as poor growth and possible loss of weight, it was surprising and very concerning that these injuries were not linked to those concerns.”

The board said: “It could be argued that had a much more enquiring mind been employed by professionals about Daniel’s care, and they were more focused and determined in their intentions to address those concerns, this would likely have offered greater protection for Daniel.”

Report author Ron Lock said: “No one professional, with what they knew of Daniel’s circumstances, suspected or could have predicted that he would be killed.

“Strong concerns nevertheless emerged about Daniel’s circumstances and his care, although at no point were practitioners who had contact with him, prepared to think the unthinkable and consider that he might be suffering abuse.

“But if professionals had used more enquiring minds, and been more focused in their intentions to address concerns, it’s likely that Daniel would have been better protected from the people who killed him.”