DANIEL PELKA: HIS LEGACY Berkshire West LSCB’s DANIEL PELKA: HIS LEGACY Preparation notes These notes are intended to be used by any person who is presenting the power point slides entitled ‘Daniel Pelka: His Legacy’. It is anticipated that the presentation will take approximately 45 – 50 minutes but can be used for a longer presentation if required by using the key questions that are included in these notes and facilitating group discussions or exercises. It would be helpful, but not essential, if the person undertaking the presentation reads through the Serious Case Review Report which can be found at http://www.coventrylscb.org.uk/dpelka.html. It is intended that all participants should be provided with copies of the power point presentation in the format that provides for notes to be taken next to each slide. There is a resources list that can be photocopied for each participant. Opening This is a presentation about a little boy who was called Daniel Pelka who was killed by his mother and step father when he was just 4 years and 8 months old. The presentation has been commissioned by the 3 LSCBs for the purpose of learning from Daniel’s life experiences. The presentation deliberately focuses on things that did not work well however, it is important to note that there were some examples of good professional practice.

Genogram Q. - What does the genogram show you? Key points include: number of partners mother had, 3 different fathers, Daniel was middle child of 3 children.

Family History 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 It was Daniel’s father, Mr Pelka who brought the family from their native country of Poland to the UK at the end of 2005. The family lived in Coventry and Daniel was born there on the 15th July 2007. Mr Pelka left the family at the end of 2008 when Anna was three and a half years old and Daniel was just over a year old. Mr A lived in the family home form late 2008 until mid-2010 (Mrs Luczak had a miscarriage in April 2009) and then mother’s third partner whilst in the UK, Mr Krezolek moved in to live with the family shortly after Mr A left. Mrs Luczak, (mother) gave birth to his child, Adam, just over a year later.

Family Features All Polish -Catholic religion English not first language Domestic abuse Alcohol misuse Mother - mental health issues House moves All the adult family members, including the different male partners, are of Polish nationality, moving to the UK as adults. None of the family spoke English as their first language. It is believed that the family were Catholic. There were also incidents of concern identified that seem to have resulted from Mrs Luczak experiencing mental health problems which included incidents of her taking an overdose. There was a catalogue of 27 domestic violence incidents reported to the Police from November 2006 through to July 2011 – these included all three partners at different times. The incidents involved slapping, threats with knives – Mrs Luczak and the males, verbal arguments and allegations of rape and attempted strangulation – some of these incidents resulted in injury and on one occasion mother’s finger was broken. A key feature to the domestic violence was the misuse of alcohol. The other key feature is the number of house moves. During Daniel’s life, the family moved at least 7 times mostly within the Coventry area. Q. - Any thoughts or comments about the features of the family? Q. - Are there any particular implications for professionals?

Daniel’s life March 2008 – laceration over eye Witnesses domestic abuse July 2010 bruise side of head Witnesses DV – knives & attempted strangulation of mother From what we know so far, it is possible to imagine how chaotic the children’s lives were living with Mrs Luczak and her different partners. Anna was noted to have had a number of what were described as minor injuries from the age of 2 years and then at the age of 8 months, the first injury to Daniel was recorded – a minor laceration to his eye – mother’s explanation was that he had rolled over whilst having his nappy changed and hit his head on the corner of a table. The children continued to witness fighting and physical abuse between their mother and her partner at the time, some of it described as ‘significant.’ In July 2010, Daniel was seen to have a bruise to the side of his head which was explained by mother as him having fallen over. The violence in the household continued despite mother telling professionals that it had stopped at different times, and the children certainly witnessed some horrifying scenes including their mother being strangled and losing consciousness and sustaining a cut from a knife. Mrs Luczak also claimed that she had been raped a number of times and that Mr Krezolek had viewed indecent images of young teenage girls. It seems that this possibly illegal behaviour was not followed up.

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 In January 2011 Daniel was taken to the A&E department by Mrs Luczak and Mr Krezolek where an examination revealed a spiral fracture of his left arm. There was also multiple bruising to the arm as well as a small bruise on his left shoulder and lower stomach. The explanation was that he had been playing with Anna the previous day jumping from the settee and had fallen on to the floor. Q. Does the explanation fit with the injury? The medical examination noted that the fracture would have involved a significant twisting mechanism and that the ‘swelling and pain would have been evident yesterday.’ The consultant paediatrician, having talked with colleagues, said that the explanation was plausible. Daniel had the arm manipulated under anaesthetic 11 days after the injury. Daniel started to attend the same school as his sister in September 2011, a month after Adam was born. There were concerns about Daniel’s obsession with food – he was seen taking food from other children’s lunch boxes, regularly saying he was hungry – he took food from the bins and other discarded food and had even tried to eat beans being planted in soil. His attendance at school was poor and dropped to 64%. He was also noted to be losing weight and between December 2011 and February 2012 he was seen at school with facial injuries. His mother explained that she thought he had a medical problem and this was being followed up by a paediatrician. Q. Any reflections on this information? Was this usual behaviour for a child? Are you aware of any medical conditions that would have led to these behaviours and physical manifestations?

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? In his Overview Report Ron Lock states “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.” Ron Lock also asks “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.” Despite considerable individual concerns by school staff, these were not developed into a coherent referral to CLYP. The school missed this clear opportunity to formally raise the level of concerns to the child protection level. Q. Why do you think this was? Finally Ron Lock surmises “The reasons why they did not do so appeared to have reflected a disorganised response to injuries witnessed, meaning that no records were made, incidents were viewed individually, and there was no person who was coordinating the concerns and identifying that a clear pattern of risk was potentially emerging. The system within the school to respond to safeguarding concerns was therefore dysfunctional at this time.” Q. Could this happen here?   Pan Berkshire Child Protection procedures are clear for all agencies around the need to refer and to escalate concerns where the response appears inappropriate or the concerns continue to exist. Para 5.29 - DUTY TO REFER TO CHILDREN'S SOCIAL CARE http://berks.proceduresonline.com/chapters/p_recog_resp.html#duty_refer. CHAPTER 44: Resolution of Professional Disagreement http://berks.proceduresonline.com/chapters/p_resolution_prof.html

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 The school nurse made a referral to the community paediatrician in October 2011 having reviewed Daniel’s health records at school – he did not attend the first 2 appointments that were sent one in November and then in December but was seen in February 2012. There was a detailed history taken from the mother that identified he had an excessive appetite and non-stop hunger leading him to steal from lunch boxes and eat from roadside bins. He was also drinking lots of fluids and soiling most days – he had also smeared faeces over his bedroom. She went on to say his relationships were poor with limited interaction and that he was aggressive towards his siblings. Apart from looking thin he had a normal physical presentation – it was noted that he wet himself at the beginning of the appointment. The paediatrician requested further investigations due to the concerns about his excessive appetite, poor weight gain and growing along the 0.4th centile – he was 13.8kg at this point. Q. What do you think about the plausibility of mother’s description of Daniel? The test results showed that Daniel was low on iron and zinc and that his sodium levels were normal but at the top of the range. The suggestion was that he should be prescribed iron syrup, zinc tablets and vitamin drops for 6 months. Q. What else would you have expected the Paediatrician to have done?

Daniel’s secret life - discovered after his death Anna’s involvement Junk or box room Withdrawal of food Use of salt Being hit Bath and nearly drowning What became apparent during the Court hearing was that Anna had been used by her mother and her partner. She was, on occasion, put in the invidious position of having to corroborate the adults story to different professionals about what had happened to Daniel – it would seem she knew the truth about what was happening but could not tell. Q. What steps can you take to ensure children you work with are not put in the same situation as Anna? Daniel experienced a harsh degree of scapegoating and emotional abuse as well as physical abuse and neglect which included him being locked in an upstairs ‘box room’ which had no furniture and smelt of urine, had a damp carpet and soiled mattress but no heater or toys; being deliberately deprived of food; seriously physically hurt; feeding him salt and putting him in a cold bath – on one occasion to the point he became unconscious; making him do sit ups, stand in the corner, do squats or running on the spot – these punishments were often planned in advance. Q. – What could you do to make sure that children are not experiencing this sort of abuse without you knowing?

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’ On the 2nd March 2012 Daniel did not go to school – the school phoned home but there was no reply. It later emerged that the family computer had been used on that day to find out about salt poisoning and a child not responding. At 3.28am on Saturday the 3rd March Daniel was admitted to hospital having suffered a cardiac arrest – he could not be resuscitated.

Missed opportunities Antenatal bookings Child development appts 27 domestic abuse events known to Police Mother’s hospital attendances Minor injuries to Anna There were a number of opportunities missed by a range of professionals involved in the family’s life which seem more obvious with the gift of hindsight, these included antenatal appointments, child development appointments, 27 domestic violence incidents, mother’s hospital attendances and the injuries to Anna. Each of these could have provided a chance for professionals to be more inquisitive about the adults’ attitudes, behaviours and circumstances

Missed opportunities Injuries to Daniel noticed by school & Paediatrician Daniel scavenging for food at school – school accepted mother’s explanation Failure of professionals to check information with each other When the injuries to Daniel were seen then there could have been a more holistic and multi-agency approach to assessing and understanding what was causing the injuries and not taking what his mother said at face value. This is also true with regards to the explanations she gave about him scavenging for food at school – this was a very unusual behaviour – and coupled with the bruising should have led staff to be more proactive in sharing the information and their concerns with other professionals and then following up on actions when there did not seem to be any progress.

Missed opportunities Assessments by social workers Males were not visible Daniel only spoken to on one occasion – issue of him speaking Polish Social workers did complete 4 assessments in total but these took an unrealistic and naïve stance about the domestic abuse and alcohol misuse stopping and there being no risks to the children. Furthermore, professionals failed to include the male adult figures in their discussions about what was happening within the family and despite recommendations from other Serious Case Reviews, including Victoria Climbié, Daniel was not spoken to alone by any of the professionals apart from on one occasion a short while before he died when a teacher spoke with him in Polish – he did not engage in any conversation.

Professional communication Impact of moves Not proactive Confused & ineffective communication Assumptions Lack of multi-agency contributions to social work assessments There appears to have been a good deal of information known about the family but as is often the case, different information and understanding was held by different professionals – the key to this was communication between the key professionals involved but there are a number of examples where there is evidence of confused and ineffective communication. This in part may be as a result of the number of house moves which resulted in different professionals being involved. However, there is also evidence that professionals just were not proactive enough in following through on what they worried about, not sharing information with one another and making assumptions about the reasons things were not done or why other professionals were no longer involved. The quality of assessments completed by the social workers were considered, overall, to be poor with limited involvement or contributions by other professionals thus limiting the opportunity for there to be a fuller multi-dimensional understanding of the family dynamics.

Professional communication Not holistic Not historic ‘Start again’ approach Incident focused Lack of child focus Lack of mgt oversight There were other key elements noted in relation to professionals’ approaches to working with the family including professionals not being holistic, not considering the historic information, succumbing to the ‘start again’ approach, being too incident focused and allowing the ‘rule of optimism’ to prevail. There was a lack of child focus with professionals seeming to fail to fully consider the life experiences of the children. And there was a lack of managers’ involvement, challenge and 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 There was some good practice with the Police undertaking ‘safe and welfare’ checks when called to the house but there needed to be a more child centred approach at all incidents. Police need to ensure that officers carry our appropriate checks, both physical and intelligence, to ensure that children are safe and well and obtain details of ALL adults forming a part of the household in whatever capacity, whether permanent or temporary. The Police always need to consider the impact of domestic violence on children and be open to the idea that even when children are not directly involved they will be affected. There is also learning about needing to ensure that notifications are sent to Children’s Services in an appropriate time scale – not weeks later and that there is a clear difference between when the Police just want to notify Children’s Services and when they are actually making a referral.

Health Visitor’s Practice Issues Lack of communication with GP’s Lack of robust attempts to complete assessments Presumption that no DV Not responsive to notifications of injury nor DV With regards to Health Visitors’ practice issues there appears to have been a lack of joined up thinking and a lack of communication with GP’s which resulted in them not having full information about the family situation and therefore not being able to make more sense of the pieces of information they had. There was a lack of robust attempts to complete assessments of the children and an overall presumption that because the mother said that things had improved and that there was no longer domestic violence, this was true. It is really important to ensure that Health Visitors are responsive to notifications of injury, concerns about families and notifications of domestic violence – this was not the case with relation to Daniel and his family.

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 As well as a lack of appreciation of the likely impact of domestic violence on the children there was also a lack of identification of the impact of Mrs Luczak’s mental health, attempted over doses and alcohol misuse – this seems to have been a particular issue with regard to hospital staff. When Daniel went to the hospital there seems to have been a disproportionate reliance on the mother’s explanation for his conditions – health staff need to be more robust in questioning parental explanations. There was too much of a focus on Daniel’s main injury without considering other his other injuries & taking a more holistic view thus seeing what was happening in context. It could be argued that it is too easy to rationalise injuries especially when parents appear to be so plausible. Health professionals need to make sure that they are responsive enough and consider child abuse as part of any differential diagnosis when there are physical injuries.

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 When Mrs Luczak discharged herself from hospital whilst pregnant with Adam there was no clarification about what was happening to her and the reasons she chose to leave the hospital although there were clear concerns about her partner’s aggression towards her – there seemed to be no consideration of her other children who were at home. The midwives were not proactive when Mrs Luczak missed 4 antenatal appointments nor when disclosed that there was ongoing domestic violence – there was an inappropriate view that domestic violence is not a child protection concern.

GP Practice Issues Failure to alert other professionals Adult focus Lack of proactive responses Need to record on adult & child records When the mother went to see the GP’s, they failed to alert other professionals about what they knew, they seem to have retained too strong an adult focus, did not act proactively and did not record key information across the adult and children’s records so that information could be cross referenced.

Probation’s Practice Issues Failed to up-date assessment when Mr A returned to home – ‘no realistic protection’ Curfew arrangements Risk assessments Adult focus The Probation Service was involved with one of Mrs Luczak’s partners, Mr A. When he was released from prison they failed to up-date the risk assessment when he returned to the family home which resulted in there being ‘no realistic protection’ of Mrs Luczak or the children. The Probation professionals maintained an adult focus and failed to consider any impact on children of the household. There ought to be rigorous risk assessments to ensure that offenders do not pose risks to vulnerable women and children.

Children’s Services Practice Issues Poor quality assessments Lack of male inclusion Disguised compliance Did not talk directly to Daniel or Anna It was noted that out of 4 assessments undertaken by Children’s Services 3 were of poor quality inasmuch they were not robust in including multi-agency perceptions nor challenging whether or not family circumstances had really changed for the better – there appears to have been a rule of optimism. Furthermore, there does not appear to have been any attempt to link the assessments or understand the history; if this had happened there could have been the possibility that social workers and their managers could have challenged any concept that patterns of domestic violence can easily stop. Given the research that suggests women will return to their partners 7 times before leaving him, it is vital that assessments include males. ‘All too often the focus of child protection assessments are on women, and this means that we are asking women to sort out the problem and operate as our agent, rather than including men and asking them to take responsibility for their violence.’ There were many examples of Mrs Luczak saying things that she either did not mean or said because she understood this is what she needed to do thus social workers were working with a situation of ‘disguised compliance’. This is a well known issue and so all professionals should be aware of the possibility that adults are only pretending. Despite the explicit expectation that all social workers must talk directly to children when undertaking an assessment, social workers failed to talk directly to Daniel or Anna. Social workers need to ensure that they consider a range of means that will enable them to talk with children even where there may be additional challenges including where English is not the first or where it is known that there are violent adults. Children living in domestic violence – towards a framework for assessment and intervention: 2004 Calder C et al

School’s Practice Issues Disguised compliance Use of interpreters Disparity of views No effective coordination with school nurses or each other Poor recording systems School staff also need to be aware of parents appearing to be working in partnership when really they are disguising the reality. It is not clear just how much English Daniel could speak or understand but it seems that it was thought little. The school did not use interpreters to try to communicate and understand what was causing Daniel to behave in the range of very unusual ways. They did not refer when they saw Daniel with bruises or scavenging for food.  There was disparity of views within the school staff about what the issues were with Daniel and very limited opportunities taken to effectively coordinate those views with each other or the school nurses and come to any sort of agreement about what was happening – this was hampered further by poor recording systems.

Consolidating & improving practice Take every opportunity Robustly challenge explanations & reassurances from parents Domestic abuse is always a child protection issue Talk directly to children – ensure no child is invisible Take every opportunity to explore and validate information and your understanding Robustly challenge explanations & reassurances from parents Always consider domestic abuse as 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 Develop understanding of patterns of behaviours and trends in incidents within families Write effective and timely records and reports Physical injuries, especially to the 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 Consider the impact of family’s circumstances – language, religion, culture and the potential for individuals within the family to be isolated, not able to access services and resources and the potential over reliance on unhealthy relationships within community networks Hold your own professional judgements – feel confident about your own competence and follow up concerns Objectively assess what real evidence there is regarding parents’ ability and willingness to change attitudes, behaviours and circumstances

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 Don’t rely on family members to corroborate information unless you can really be sure that they are not colluding or being used Don’t make assumptions - check information and professional judgements with colleagues Always consider child abuse as a potential cause and retain healthy scepticism when working with families.

Daniel’s mother & her partner, Mr A, were charged with Daniel’s murder and received sentences of 30 years imprisonment in July 2013. Daniel’s mother & her partner, Mr A, were charged with Daniel’s murder and received sentences of 30 years imprisonment in July 2013.  Any questions?