Comment: Daniel Pelka Serious Case Review
Serious Case Review into Daniel's death raises questions about missed opportunities to save his life
17 September 2013
The Serious Case Review (SCR) into the death of Daniel Pelka found no blame or failure with any individual party but raises concerns about the current practices being too process-driven.
Peter Wanless, CEO of the NSPCC, said:
"It’s important to remember that only two people are ultimately responsible for little Daniel Pelka’s death - his mother and her partner. However, it’s right that we look at missed opportunities and what could have been done differently.
"Whilst this SCR judges that no single, specific failure led to his death, time and again we see a basic lack of real action to protect Daniel. Processes were followed correctly much of the time but processes alone do not save children.
"Excuses from Daniel’s violent, drug using and alcoholic parents were believed. Medical opinion, which ultimately turned out to be wrong, was taken as concrete fact. Too often people failed to look at Daniel like they would their own child. He was clearly not OK and it’s not clear if anyone sought to establish his feelings with him in his own language as his parents’ excuses just didn’t add up.
"The police and other services were involved with the family many times about his parents’ domestic violence and alcohol issues - on at least 27 occasions. The impact on children that a series of violent family incidents would have had does not seem to have registered with children’s services. This is shocking when the high risk of children suffering both physical and emotional harm in these circumstances is well known.
"Daniel wouldn’t have cared what type of professional helped him - he would have just been screaming inside for anyone in authority to notice what was going on. Everyone who has contact with troubled families through any role, particularly adult focused services, needs to think about every person in that house.
"Sadly there are no quick fixes that will stop this happening again. There must be a culture change from process driven box-ticking to child-aware curiosity; a willingness to question excuses; and a resolve to record and follow through with appropriate urgency whenever we see a child suffering.
"Professionals must act on their instincts when they feel something could be seriously wrong, not wait until they are certain. Tragically, in Daniel’s case, this failure to see and act at speed may have cost him his life. SCRs like this one have generated enough lessons now - we owe it to Daniel to ensure they are learnt, not filed and forgotten."
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