Daniel Pelka: The mistakes we keep making

Daniel Pelka Daniel died age four after being beaten and starved by his mother and stepfather

The tragedy of Daniel Pelka is that he is not the first and won't be the last child to be tortured and killed, apparently hidden in full public view.

We wring our hands and promise lessons will be learned, but little Daniel's death bore many of the hallmarks of past failures. Tuesday's report echoes reports written many times over the past few decades.

"At times, Daniel appeared to have been invisible," says the Serious Case Review (SCR), noting that "there was very little evidence that Daniel was ever spoken to individually alone about his wishes and feelings."

When Ofsted pulled together the lessons from almost 200 serious case reviews involving the deaths of 60 children, they concluded that "too often the focus on the child was lost… their voice was not sufficiently heard."

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Classic warning signs - domestic violence, alcohol abuse - were not flagged”

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The importance of talking to the children has been reiterated often and yet Daniel appears to have been quite alone, a vulnerability increased by his "poor language skills and isolated situation".

The report says professionals need to "think the unthinkable", rather than accept parental versions of what was happening. We've heard that many times before, too.

In his 2003 inquiry report into the death of Victoria Climbie, Lord Laming wrote of the need for "respectful uncertainty" among social workers; that they must be more sceptical and mistrustful about what might really happening behind closed doors.

The death of Baby Peter Connolly, five years later, was cited as evidence that children's services did not learn that lesson. Social workers remained "over optimistic", as Lord Laming put it - too trusting.

Victoria Climbie, who died age eight Victoria Climbie froze to death after being forced to sleep naked in a bath

Those professionals with a responsibility to keep Daniel Pelka safe are said to have fallen victim to that same "professional optimism". Today's review talks of their naivety, of how the manipulation and deceit of Daniel's mother "were not recognised for what they were and her presenting image was too readily accepted".

"The 'rule of optimism' appeared to have prevailed," the review concludes.

Almost exactly the same was said about the professional response to Peter Connolly's mother. She too was deceitful and manipulative and her little boy may also have died because agency workers were too quick to believe her stories.

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We may simply not be able to prevent more children suffering”

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Ofsted's review of serious case reviews makes exactly the same point. Again and again there was "insufficient challenge" by those professionals involved, the statements of parents or others in the family accepted at face value.

There's another theme that emerges from Ofsted's review of child abuse tragedies. Different agencies held different information but didn't talk to each other. And, of course, that was precisely what went wrong with Daniel.

Classic warning signs - domestic violence, alcohol abuse - were not flagged so doctors and teachers could not get a full picture of how chaotic and abusive family life had been.

When Eileen Munro published her review of child protection for the current government in 2011, she emphasised, yet again, the importance of a system in which encourages "professions to work together well in order to build an accurate understanding of what is happening in the child or young person's life, so the right help can be provided".

Box room The room - with door handle removed - in which Daniel was regularly locked

One thought emerging from Tuesday's SCR is to make it mandatory for professionals to report every suspicion that a child may be being abused or neglected. It is an approach that already operates in Australia.

This seems an attractive idea at first sight, ensuring that warning signs don't get ignored and that the various dots of a child's life can be joined up.

But social workers and others may be cautious about introducing mandatory reporting in case it produces so many warnings - many of them unfounded - it blinds professionals to the most serious abuses.

There is no easy way to protect children but it seems we make the same mistakes again and again - well-meaning professionals overly optimistic and not talking to each other.

Endless reviews and reports attempt to tweak the protocols and procedures to prevent those mistakes, but then you risk a tick-box culture in which individuals are not permitted to use their professional judgment or common sense.

The real tragedy of Daniel Pelka is that we may simply not be able to prevent more children suffering and ultimately dying, hidden in public view.

Mark Easton Article written by Mark Easton Mark Easton Home editor

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  • rate this

    Comment number 38.

    I have previously worked as a qualified social worker. Professionals in different agencies don't necessarily respect one another or their opinions, which is why I think there are so many failures in communication between them, and why such failures, which have been highlighted for decades, will continue to be a significant problem in child protection cases, as well as in adult protection.

  • rate this

    Comment number 37.

    Is the problem not to do with not having a single body with responsibility for child protection and information sharing. I recall that the Yorkshire Ripper case highlighted the importance of intelligence in identifying criminal activities and changes were made as a result of this case. Police forces also have access to sophisticated analysis tools. Although how did people miss the signs here.

  • rate this

    Comment number 36.

    same old excuses and we'll learn lessons is the explaination well numerous cases say you havent!
    time for a different approach if you cannot gain access to a child after say three attempts due to delaying tactics from the parents get the police to smash the doodr down, better to replace a door than a life

  • rate this

    Comment number 35.

    A young girl aged 12 being picked up by a gang of older asian men in a car, a child covered in bruises, a young boy who is eating out of a dustbin. Im sorry but did the care home workers, social workers, police officers, teachers or GPs see any of the warning signs? Pure neglegance of duty and care. Its time we stopped hiring people with degrees and employed people with life experience.

  • rate this

    Comment number 34.

    Where were the grandparents, friends of the family, and people who in general knew the child and parents when all this was going on?

    Should we not be blaming them also.

    No, far easier to blame "nanny" for not doing it's job properly than to blame the people who really are to blame.

  • rate this

    Comment number 33.

    social service take to much time to look and broke a normal family who have small issue. but when come to bigger issue they are closes they eyes cos is to much to deal with it. they are not good at all.

  • rate this

    Comment number 32.

    It's difficult to comprehend why these children's injuries are not discovered early? Social workers should be allowed to refer suspicious cases for an Immediate medical.

  • rate this

    Comment number 31.

    "Daniel Pelka: The mistakes we keep making"

    We keep making? No, no the government keep making.

    I'll be surprised if anyone loses their job over this, and in the very unlikely event they do, it will be accompanied by a massive pay off. And the thought of someone actually getting prosecuted for gross negligence is laughable.

    But put garden waste in a food waste bin wowzers you’ll get hammered!

  • rate this

    Comment number 30.

    You'll excuse me if I find it incredible that no-one picked up on the fact that he was covered in bruises and scavenging for food from bins at school. Where on earth was the common sense in all this? Buried under a mountain of political correctness, perhaps?

  • rate this

    Comment number 29.

    Social Services seem to deal with these situations in cycles:

    We have a few years of them trying to be "hands off" and children die.

    There is a shake-up, and then we have a few years of them overzealously taking children into care, destroying families.

    Another shake-up and we go back to "hands-off".

    On top of that, we can only prove when they get it wrong, not when they get it right.

  • rate this

    Comment number 28.

    Surely the SCR only told us what we already knew? Will it happen again, you bet your ass it will! A child scavenging for food, losing weight? Your gut instinct would tell you he is starving and any professional worth his salt should demand evidence to the contrary. Teachers, doctors and social workers should hang their heads in shame.

  • rate this

    Comment number 27.

    So often the abusing parents use every trick in the book to make sure that social workers can never get into the house, or see the child on its own. My suggestion is that missed appointments are never tolerated. The parents should be warned that if access to the house can not be gained, police WILL break down the door and the house searched. The child WILL be interviewed on its own.

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    Comment number 26.

    Totally agree with Shabutie-I know people in the social work profession and they are over-burdened with cases because their "managers" are not doing their job properly i.e. managing. These people are happy to take large salaries but suddenly become invisible when it comes to accepting responsibility for incompetence.

  • rate this

    Comment number 25.

    If anyone believes that children are the only people who are in the purview of social services to suffer from problems of lack of care then think again.

    Social services rely on hardheaded protocols and they always believe that the courts will protect them. It is time for the rug to be pulled.

  • rate this

    Comment number 24.

    I agree with Michael F C. The public service culture and those they recruit is to blame. If you have ever read the descriptions and language used in applications for health, social workers, and teachers jobs you may understand why no one is challenging and no one will take individual resonsibility for bad decisions. It will happen again. We need to stop recruiting these ineffective people.

  • rate this

    Comment number 23.

    It’s all due to an institutionalised left wing public sector culture. The same culture that turned a bind eye to Jimmy Saville.

  • rate this

    Comment number 22.

    In safeguarding children training the one thing that always gets mentioned first is that safeguarding children is everybody’s business.

    However when something like this happens, it seems that one profession gets the blame? (I'm not one by the way).

    I'm also wondering if the austerity 'efficiency savings' might have played a part?

    And who's responsible for that?

  • rate this

    Comment number 21.

    Stop cutting funding and firing staff and services will improve, social workers can't perform miracles like managing 100+ cases with the right level of detail.

  • Comment number 20.

    This comment was removed because the moderators found it broke the house rules. Explain.

  • rate this

    Comment number 19.

    The number of children taken into care has increased hugely since Baby P. Social workers are criticised for 'mistakenly' separating a child from its parents, or leaving it with them, but never receive public acclaim for saving a life. Whilst necessary to analyse cases such as these for shortcomings, it is hard to legislate against people who are so commited to acts of evil against a child.


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