Reaction to Daniel Pelka serious case review
A serious case review has found that opportunities were missed to help four-year-old Daniel Pelka, who was murdered by his mother and her partner in Coventry.
It said Daniel was "invisible" at times and none of the professionals he came into contact with ever questioned him about what was happening in his life.
A number of the bodies cited in the review have responded to its findings.
Ron Lock, author of the serious case review
Mr Lock said there were a number of features of Daniel's case which made it very unusual.
"Often abuse is about parental stress... reckless behaviour by parents, and the abuse of a child is a follow-on from that. In this case, it was premeditated and planned.
"Now that's quite rare and I think people actually struggled to believe what was happening.
"The other thing that was different was Daniel was scapegoated and was the only child in the family that suffered this level of abuse. That in itself is quite rare... so there was a reassurance that if the other children appeared well there must be something else to explain away what was happening to Daniel.
"There is a rule of optimism that prevails. I think there were too many occasions when, for instance, mum said, 'We've stopped drinking, the domestic violence has stopped.' There's an optimistic stance that can then allow the social worker or the police officer or the health practitioner to move on to their next case.
"There's no doubt that Daniel was the focus of professional concern... But he was not the focus of their interventions. I didn't see a record of any conversation with Daniel. I didn't see a time when someone sat down with him and tried to explore his wishes and his feelings."
Amy Weir, independent chair of the Coventry Safeguarding Children's Board
Ms Weir told the BBC she found the report "disheartening, disappointing and worrying".
"I think there were some things in the way that he presented which I suspect arose out of having been abused and neglected over many, many years... so that he was very controlled, did not speak very much. Of course, there was the issue about him mainly being Polish speaking.
"Clearly, that was difficult for professionals, but it's my opinion that should have been overcome and should have been seen through. He had that entitlement, that right to be heard, as did his sibling.
"In terms of his mother, I think there are significant issues about her and her partner, and partners previously, about deception, about trying to hoodwink the professionals.
"Above all, going forward nationally, we've really got to get this message across to all professionals… they have got to see the child as the main element of their focus."
Sharon Binyon, medical director of the Coventry and Warwickshire Partnership NHS Trust
Ms Binyon said that while "no one professional, or professional group, was to blame for this, we didn't do enough working across the service".
"The doctor that Daniel saw was a very experienced community paediatrician and he was faced with information which suggested that Daniel was losing weight despite the fact that he was eating. And also, when he did his own assessment, including examination, he saw no signs, there were no bruises on the child when he saw him.
"Every experienced doctor would always have child abuse in the back of their mind. At that time, when he saw him, that wasn't what the symptoms and signs were leading him to investigate.
"In the trust, we see at least one child a week referred with low weight, and the vast majority of those will turn out to have physical illness and the information that's being given by the parents and carers will be accurate and correct. So I think that was the starting position for the paediatrician.
"Unfortunately, he was killed before he was able to pursue his investigation, when he would have reached the different conclusion."
Martin Reeves, chief executive of Coventry City Council
Mr Reeves said every agency in Coventry "needs to stand up and take responsibility individually and collectively for missed opportunities to have protected Daniel better".
"We must have a situation whereby people will be able to stand back... join the dots up and make that decisive judgment call. Judgements which are really difficult, arguably impossible sometimes, about the right thing to do regarding a child and their family.
"There's absolutely no doubt that certainly slightly earlier in Daniel's tragically short life… the tone that was set of optimism with regard to what was being told to them should have been challenged and should have been arguably more pessimistic.
"The overriding emotion genuinely [now]… is a determination. We don't vilify professionals... but we say, we're not going to have the same conversation in a year, two years' time about information that could have been shared more readily.
"We can never say that a situation like this will never occur again but we must be able to say that the same mistakes… mustn't be replicated."
David Simmonds, chairman of the Local Government Association's children and young people board
Mr Simmonds said there must be "a culture of moral responsibility" in which people know how to raise the alarm and feel confident they will be listened to.
"The proposed change in the law to strengthen the legal responsibility to report suspected abuse may be one element of driving the necessary cultural change."
But he added: "We must avoid creating a situation where the social care system is swamped with unnecessary referrals because professionals lack the courage or confidence to take responsibility, exercise their judgment and act appropriately."
Asst Ch Cons Garry Forsyth, West Midlands Police
Police were called to 26 separate incidents at Daniel Pelka's home and Asst Ch Cons Garry Forsyth said more could have been done to see them in the round.
"As the serious case review points out, the police dealt reasonably well with all the incidents in isolation. What we didn't do so well was deal with them on a linked-up basis and we didn't actually do as much with Daniel as we perhaps had the opportunity to do.
"Clearly there are things that needed to be done better and we've made lots of effort to ensure that we've learned those lessons.
"In any domestic abuse case I want my officers to be really consciously aware that children who are involved in that are always a child protection consideration."
Peter Wanless, NSPCC chief executive officer
"Whilst this serious case review 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. Too often people failed to look at Daniel like they would their own child.
"He was clearly not okay 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."