Everyone to blame but no one punished: Teachers, doctors, the police and social workers escape justice after missing 27 chances to save tragic Daniel Pelka



Magdalena Luczak and Mariusz Krezolek found guilty of murdering Daniel

Review looked at how he was starved and beaten but ignored by authorities

Police were called to his home 26 times but failed to ask enough questions

Little boy forced to scavenge food from school bins and steal from friends



Arrived at school with black eyes, broken arm and looked 'a bundle of bones'

Yet 'invisible' boy, 4, was never asked about his tortuous life at home

Police, health and social workers did not dare to 'think the unthinkable'

Not one person has been disciplined for failing to protect Daniel from harm



Innocent child: Chance after chance was missed to save murdered four-year-old Daniel Pelka, a report found today

A boy of four was allowed to be tortured to death by his parents because teachers, medics, social workers and welfare officers failed to ‘think the unthinkable’, a damning report found yesterday.

Daniel Pelka was starved, tortured and then beaten to death in an ‘incomprehensible’ campaign of cruelty by Magdalena Luczak, 27, and Mariusz Krezolek, 34.



But despite a review of the shocking case, none of the professionals involved have been disciplined over the murder.

Deputy Prime Minister Nick Clegg said the boy simply ‘fell between the cracks’.

The review found Daniel was effectively ‘invisible’ to officials in Coventry, who failed to speak to the Polish child about a home life in which he was starved, poisoned with salt and held in a bath until he passed out.

It has emerged police were called to his home 27 times in his short life as his drunk mother got into violent rows with various lovers, often with the schoolboy watching.

Before his death Daniel resembled a ‘concentration camp victim’, weighed just 11kg and was so hungry teachers saw him eating food from bins and the school sandpit.



A serious case review released this morning concluded 'at no point were practitioners who had contact with him prepared to think the unthinkable and consider that he might be suffering abuse'.

She added: 'I think there's another issue for us too, which is we've learnt a great deal in recent years about dealing with instances of domestic violence. I think one of the issues that the Daniel Pelka case raises is that when people are looking into issues of domestic violence, making sure we look at how those incidents affect children.'

Home Secretary Theresa May told Sky News: 'In relation to the Daniel Pelka case obviously there are lessons to be learned.



'I'm pleased the Government enables these reviews now to be published so we can actually see where issues arise. We can genuinely learn the lessons.



'I think all the agencies have recognised that they need to look at how information is shared between people.'

Despite a series of appalling blunders by police, social workers, teachers and NHS staff in Coventry, no-one has been sacked or even disciplined for their failure to protect him.



Luczak and Krezolek were jailed for 30 years each last month after they starved Daniel, force-fed him salt, tortured him and locked him in a tiny room to sleep alone on a soiled mattress before murdering him with a massive blow to the head.



In the months before he was killed in March 2012, Daniel arrived at school with black eyes and a broken arm but no action was taken because teachers 'too readily accepted' they were accidents, experts found.



Just days before he died he was described as 'looking like an old man' with sunken eyes and appeared to be 'sad, desperate and lonely'.

But despite weighing less than a toddler, his serious injuries and being withdrawn, professionals treated him as 'invisible' and never asked him what life was like at home and if he was unhappy.



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Callous: Magdelena Luczak, the mother of Daniel Pelka, and Mariusz Krezolek, his stepfather of Daniel Pelka battered him to death after subjecting him to systematic starvation and 'incomprehensible' cruelty



Murdered: Daniel Pelka who died last year after months of abuse at the hands of his mother and stepfather

His mother often got into drunken rows with a series of lovers, sometimes involving knives, yet 'child protection risks in this volatile household were not fully perceived or identified', the damning report says.

'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 review found.



FINDINGS FROM THE REVIEW INTO DANIEL PELKA'S TORTUOUS DEATH

1. 'Daniel's mother and stepfather set out to deliberately harm him and to mislead and deceive professionals about what they were doing' 2. Police were aware of domestic abuse and violence alongside excessive alcohol use by Daniel's mother since 2006 yet 'child protection risks to the children in this volatile household not fully perceived or identified' 3. When Daniel arrived at school with a broken arm it was 'too readily accepted by professionals as accidentally caused' 4. 'The school began to see a pattern of injuries and marks on Daniel during the four months prior to his death, and these were not acted upon ' 5. ' At a paediatric appointment Daniel’s weight loss was not recognised and child abuse was not considered as a likely diagnosis for Daniel’s problems'. 6. 'At times, Daniel appeared to have been "invisible" as a needy child' 7. 'His poor language skills and isolated situation meant that there was often a lack of a child focus to interventions by professionals' 8. 'Professionals needed to “think the unthinkable” and to believe and act upon what they saw in front of them, rather than accept parental versions of what was happening at home without robust challenge' 9. The level of abuse Daniel suffered that emerged in the murder trial of his parents 'was completely unknown to the professionals who were in contact with the family at the time'

'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.



'Of particular note was that without English as his first language and because of his lack of confidence Daniel's voice was not heard throughout this case.'

In March 2012 the four-year-old died at the hands of his mother and step-father, Magdalena Luczak and Mariusz Krezolek, under the noses of health professionals, school staff and social workers.



The serious case review found repeated failures by the agencies set up to safeguard children's welfare but concluded nobody could have predicted his death.

Experts found Daniel was at times 'invisible' because of controlling Magdelena Luczak and brutal former soldier Mariusz Krezolek, who 'misled and deceived' a host of child protection agencies by spinning a 'web of lies' to conceal systematic abuse of the boy.

Luczak and Krezolek, both originally from Poland, were convicted of the youngster's murder following a trial earlier this year and are now each serving a minimum of 30 years in prison.

During their trial at Birmingham Crown Court, the jury heard how Daniel had been kept locked in a box room as a virtual prisoner - at one point his mother held his head under water in the bath.

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 and co-ordination between the different child protection agencies, and a strengthening of working procedures and staff training.

Final days: CCTV grab of tragic Daniel Pelka with friends at school just days before he was murdered



Prison: The tiny unfurnished box room that Daniel was locked in for hours on end. The urine-soaked room had only a mattress. The door had been tampered with so Daniel could not get out

Filthy: A dirty mattress Daniel Pelka was forced to sleep on during his confinement in the box room in his home in Coventry

Published in the report for the first time are West Midlands Police logs, revealing Luczak had three consecutive partners who were abusive to her, and charting how officers would be called to the family home to find one or other of the adults drunk.

'The practitioners involved were not prepared to “think the unthinkable” and tried to rationalise the evidence in front of them that it did not relate to abuse. 'Daniel’s voice was not heard throughout this case. There is no record of any conversation held with him by any professional about his home life. He appeared to have been "invisible".' - Serious case review into the death of Daniel Pelka



In one incident in 2008, Luczak, 27, was reported as being in the street having taken an overdose 'because her partner had left her', although no reference was made to Daniel who would have been six months old at the time.

In another in May 2010, officers arrested Krezolek on suspicion of assault at home after Luczak claimed he had slammed her finger in the door, with police recording that Daniel was at home at the time.

Officers responding to a call to the family home involving a knife in August that year, reported that Luczak was claiming Krezolek, 34, had attempted to strangle her, while in December 2010 a neighbour called to say Luczak had 'locked children in the house' and there was 'lots of screaming and shouting'.



On that occasion, no checks were made on the children although the matter was referred to the police's public protection unit.

The safeguarding children board said there was 'inconsistency' in when referrals were made by the police and how they were dealt with.

The review also looked at several missed opportunities by child welfare agencies to intervene on Daniel's behalf, including in January 2011, when he was brought in to accident and emergency with a broken arm caused, his mother and stepfather falsely claimed, when he jumped off a sofa at home.

Convicted killers: Magdelena Luczak, Daniel's mother, and his stepfather Mariusz Krezolek who were found guilty of murder by a jury at Birmingham Crown Court

Murdered schoolboy: The catalogue of injuries inflicted on little Daniel Pelka, which were found when his body was examined

A doctor did refer the issue to social services, who then carried out an assessment, but a follow-up was deemed unnecessary.

Deceit: Magdelena Luczak, Daniel's mother, blamed an eating disorder to hide her cruelty towards her son

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 Little Heath Primary School in Coventry, teaching staff noticed Daniel was 'wasting away' and had been caught stealing food from other children's lunchboxes or stealing scraps from the bins - but his behaviour was put down to a medical condition rather than child abuse.

However, the report noted there was a general 'lack or urgency' by most health professionals to have any such issues attended to by a paediatrician, doctor or school nurse - not helped by Luczak's 'deception' as the caring mother.

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.'

The report did add there were efforts made by the school to inject urgency into Daniel's case, with the school nursing support worker highlighting her concerns when Luczak cancelled the second of two paediatric appointments, and the deputy headteacher 'taking the unusual step' in January 2012 of calling his GP.

However, the GP's recommendation was to ask Luczak to make an appointment, while the case review team reflected a more 'pro-active' position should have been taken.





THE ROLL CALL OF SHAME

THE HEADTEACHER

The report states that staff at Little Heath Primary School failed to react properly to Daniel’s injuries. Headmaster Darren Clews and Daniel’s teacher Lisa Godfrey both resigned soon after the boy’s death – but while it is understood that Miss Godfrey felt unable to return to teaching, Mr Clews was soon installed as head at another Coventry school. He said yesterday that he and his colleagues had ‘followed all the procedures’.

THE COUNCIL BOSS

Colin Green announced plans to retire as the head of schools and children’s services in Coventry after the city’s primary schools came bottom of a national league table. When Daniel’s parents were convicted, local MP Geoffrey Robinson called for Mr Green to leave his £124,000-a-year post a month earlier than planned, and take with him the ‘indelible stain of Daniel’s cruel death which his department failed to prevent’. Mr Green ignored this, and retired at the end of last month.

THE PAEDIATRICIAN

Dr Supratik Chakraborty saw Daniel three weeks before his death. The report did not cast doubt on hiscommitment to ‘do the best for Daniel ... in the belief his condition was related to organic causes’, but said that in the context of the boy’s turbulent home life, ‘abuse or neglect’ should have received more serious consideration.

The report also noted an appointment with the community paediatrician in February 10, less than a month before Daniel's death, was 'a key opportunity' to intervene, but again the signs of emotional and physical abuse were missed.

The case review's authors also noted their 'concern' that when Daniel turned up to school with injuries, these were not properly recorded, concluding it was 'apparent the school did not have clear protocols'.

Final hours: Daniel (circled in green) is seen leaving Little Heath Primary School in Coventry with his mother (circled in yellow) just 36 hours before he died

Schoolboy: Little Heath Primary School in Coventry, West Midlands, where Daniel Pelka was a pupil. He used to scavenge food from bins in the weeks before he died because he was so hungry

Concluding the report, the safeguarding children board stated too often concerns about the boy's health had been 'viewed in isolation'.

Addressing the question of whether Daniel's death could have been preventable, 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.'

The report's 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.

'This was a complex and tragic case.

'Daniel's mother seemed plausible in her concerns about him, and no concerns were expressed by neighbours or the wider community'.



13 MONTHS WHERE AUTHORITIES MISSED CHANCES TO SAVE DANIEL

January 5, 2011: Daniel's left arm was broken and he is taken to hospital

January 17, 2011: Social services contact his parents but his step-father tells them: 'In Poland when a child breaks his arm, the doctors look at the child, not the parents. September 2011: Daniel starts at Little Heath Primary School where health workers notice how thin he is.

August to December 2011: Daniel seen taking food from other children's lunch boxes, a problem which became progressively worse. Social Services also visit his home. Daniel had been absent for 24 days that term alone.

January 16, 2012: Teacher spots four dot-shaped bruises around the right side of Daniel's neck, which were recorded in the school's concerns book.

February 2012: Step-father Luczak was again spoken to by school staff and assured them Daniel was seeing a doctor for his problems.

February 10, 2012: When the school closed for an extended half-term, teacher also reported seeing Daniel with two black eyes and a scratch of his nose. He was seen by a doctor after a referral made by the school nurse February 27, 2012: Daniel 'looked like an old man' with sunken eyes and appeared to be 'sad, desperate and lonely' as he ate dried beans in a sand-pit.



March 2, 2012: The four-year-old was murdered

Coventry City Council chief executive Martin Reeves said: 'Daniel was murdered by the two people who should have loved and protected him most, but all organisations in Coventry involved in Daniel's short life now have to face up to their responsibilities and the part they played in the missed opportunities that could have protected Daniel.

'We are sorry we did not do enough to protect Daniel.

'The report makes clear that the sharing of information and communications between all agencies was not robust enough and no-one fitted together the jigsaw of what was really happening to Daniel.'

Mr Reeves said the council had already improved working practices and training for its social workers and staff in schools.

Assistant Chief Constable Garry Forsyth, of West Midlands Police, said the force had improved its safeguarding children processes and information-sharing with partner agencies and accepted there needed to be 'a more holistic approach when dealing with multiple incidents involving domestic abuse, in particular where children reside'.

Russell Hobby, general secretary of the National Association of Head Teachers, said: 'NAHT firmly believes that the leaders and staff of Little Heath acted properly on the information available and within the limits of the powers they had been given. It is extremely important to remember that no amount of vigilance by a school can compensate for the wilful misdirection of a deceptive and manipulative individual. Daniel was murdered by his mother and her partner, not by his school.'

Children and Families Minister Edward Timpson has now written to the board asking for further analysis of why the failures happened.

'The fact that, according to the report, there is 'no record of any conversation held with him by any professional about his home life, his experiences outside of school, his wishes and feelings and of his relationships with his siblings, mother and her male partners' speaks volumes.'

Devastated father: Eryk Pelka, Daniel's biological dad, leaves court after giving evidence against his son's mother and stepfather at an earlier hearing during the nine-week trial

Spotlight: Headteacher Darren Clews took no action when staff told him they were worried Daniel Pelka had been beaten by his mother

But the British Association of Social Workers (BASW) questioned the effectiveness of serious case reviews, expressing concern that the findings are not properly shared with child protection social workers.

Research carried out by the BASW found one quarter of its members never get the chance to read serious case review reports when they are published.

It found 67% of the 238 social workers questioned said they 'only sometimes' get to read the recommendations from reports, and 17% never do.

Meanwhile 97% said they would like to see an online database of all reviews for them to access easily.

BASW Chief Executive Bridget Robb said she would like to see better use of serious case reviews as a learning opportunity for all professionals tasked with protecting children.

'We can understand the public perception that when serious case reviews are published there is a surge of publicity but then nothing much seems to be done with the findings,' she said.

'Serious case reviews focus on what was unique in each case. If they are to be used for professional learning, we also need them to identify a few key messages for everyone. This is not straightforward to do, but essential if they are to have wider use'.

Dr Sharon Binyon, medical director at the Coventry and Warwickshire Partnership NHS Trust, said that improvements had been introduced, including better reporting of domestic violence, with school nurses and health visitors informed if any child is in the household.