What happened?
Just after 3.00am on Saturday the 3rd March a telephone call was made by Daniel
Pelka’s mother to the ambulance service in respect of Daniel who was then aged 4
years and 8 months old. The ambulance service attended the home and Daniel was
subsequently admitted to hospital after having suffered a cardiac arrest. He was
pronounced dead at 3.50am. At the time of his death Daniel weighed just 10.7kg1
(1.68st – dehydrated weight). He was found to be malnourished and also had an
acute subdural haematoma2 to the right side of his head, as well as other bruises on
his body. Subsequent pathological examination also identified older mild subdural
haematoma of several months or years duration.
Daniel was the middle child of a family who had migrated to this country in 2005 from
Poland and who lived in Coventry for most of the time that they resided in the UK.
Daniel lived with his mother and her fourth partner along with his older sibling, known
as Anna, aged 7 years and a younger sibling known as Adam, aged 1 year.
On 31 July 2013, his mother and her partner were found guilty of the murder of
Daniel and sentenced to a minimum of 30 years each.
What were the circumstances that led up to Daniel’s Death?
Daniel’s father brought the family to the UK in 2005 and remained with the family until
his return to Poland in 2008. During that time the first reported incident of domestic
abuse took place. Both adults were intoxicated and were violent and Ms Luczak3
(Daniel’s mother) was pregnant with Daniel. From that first incident and until 2011,
the police responded to a total of 27 reported domestic abuse incidents. Many of
these were fuelled by alcohol and involved violence which sometimes resulted in
injuries to Ms Luczak. Police carried out safe and well checks4 following each
incident and were noted to have said that the ‘children were none the wiser’ as they
did not witness the violence. It was also suggested Ms Luczak could not live without
cannabis and amphetamines but this information was never recorded or shared.
What was clear was that Ms Luczak was suffering with depression and was regularly
1 Average weight for a 5 year old child is 17.7kg (2.8 st). 2 A subdural haematoma is a collection of blood on the brain and are usually the result of a serious head
injury. When one occurs in this way it is referred to as “acute” and is among the most serious of all head
injuries. The bleeding fills the brain area very rapidly, compressing brain tissue This often results in brain
injury and may lead to death” National Library of Medicine – July 2012. 3 (no connection as made between her surname and that of Daniels on GP records
4 This is to simply check whether the children are present and that they have been seen and are in
reasonable health and are safe – it does not consist of any additional form of detailed assessment of the
children’s condition.
STAFFORDSHIRE & STOKE-ON-TRENT SAFEGUARDING CHILDREN BOARDS
LESSONS TO BE LEARNED BRIEFING NO. 16:
IN RESPECT OF THE DEATH OF DANIEL PELKA- COVENTRY, 2013
www.safeguardingchildren.stoke.gov.uk
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misusing alcohol; on two occasions she took an overdose resulting in hospital
treatment5
.
The family experienced a chaotic lifestyle, with many house moves,
6 some as a
result of eviction. Due to both adult’s immigrant status and the fact that Ms Luczak
had not worked for a year in England the family were not entitled to key state benefits
such as housing benefit or free school meals for the children. It was therefore clear
that the family would have struggled to maintain a basic level of existence. No
assessment ever took this fact into account or considered the impact this would have
had on the needs of the children.
Despite the difficulties, both Daniel and his older sibling Anna did attend school but
issues began to arise with regard to their attendance and injuries to Daniel. Anna
settled in well, making friends and even attending a small group with children of the
same nationally. In contrast, Daniel was known to be withdrawn and solemn, showing
little interaction with other children. His main difficulty was the barrier caused by his
language as he knew less English than a 2 ½ year old. This led school staff to either
rely on his gesticulations as a way of communicating, or on Anna and his mother as
translators.
It was felt that school was somewhat of a refuge for Daniel. When Daniel was the
particular focus of concern, the school failed to keep accurate records and school
staff did not collectively nor coherently generate their concerns in respect of neglect
into a child protection referral. No attempt was made to speak to Daniel and because
of the communication difficulties he became an invisible child and his thoughts,
wishes and feelings were not appropriately sought. Furthermore, no assessment7
was undertaken to determine the level of risk or the needs to Daniel or those of his
sister.
Very little was reported about Adam, who was just 7 months old when Daniel died.
Whilst pregnant with Adam his mother was consuming alcohol and suffering with
bouts of depression. It was not known whether Adam had witnessed any domestic
abuse but it is known that the home environment was sometimes a violent place to
be. Adam also became a lost child.
In 2011, the school became concerned about Daniels obsession with food as he was
taking food from other children’s lunchbox and eating secretively. School responded
by locking food away as they had been told by Daniel’s mother that the reason he
was so hungry was due to a medical condition. Unbeknown to the school Daniel was
being deprived of food. When confronted about their continued concerns about
Daniel being hungry his mother stated that Daniel was getting up in the night and
eating plenty of food and this information was taken at face value without being
verified.
5 The term “toxic trio” is used to describe the co-occurrences of mental health problems, substance
misuse and domestic abuse in families and is a common feature in serious case reviews. Children of
parents who are affected by the toxic trio are at an increased risk of significant harm.
6 Evidence from research indicates how children develop certain resilience and coping strategies,
coupled with the level of domestic violence. Hague et al 1996 and Mullender et al 1998, in
“Domestic abuse and Child Protection – Directions for Good Practice” Humphreys, C &
Stanley, N – 2006 Jessica Kingsley.
7 In this instance the review refers to the assessment in terms of the use of a CAF –
Common Assessment Framework
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Her ability to draw professional’s attention away from allegations of harm is common
is most serious case reviews and is known as ‘disguised compliance’
8
. In reality he
was being beaten and starved. As punishment for stealing food, he was force fed
salt, made to sit for a considerable time in cold baths and locked in a room at home
with no door handle. The room smelt of urine and had no furniture other than a
mattress which was soiled and there was no heater or toys in the room. The ‘box
room’ was apparently used as a form of punishment which was referred to as such in
text messages between Ms Luczak and her partner. No information was received
that suggested professionals ever saw where Daniel slept.
Throughout Daniel’s short life, a string of appointments were made with health
visitors, GPs, community paediatricians and the school nurse. Most of these resulted
in non attendance, with some cancelled then rearranged. Concerns within the serious
case review were raised around the way in which agencies lacked the ability to share
information, either through lack of communication, inadequate IT systems, poor
record keeping or through assumptions around culture and language. A number of
missed opportunities by professionals and agencies enabled the abuse to continue
and were contributing factors identified as lessons that needed to be learnt from the
review into Daniel’s death.
What do we need to learn from this case?

8 Brandon, M. et al. (2008a) Analysing child deaths and serious injury through abuse and neglect:
what can we learn? A biennial analysis of serious case reviews 2003-2005. Research Brief DCSFRB023
(PDF). London: Department for Education (DfE).
It’s hard to imagine what it was like for Daniel and his siblings. What is perplexing
is that within all the agency serious case review reports there is no record of any
conversations with Daniel by any professional about his home life, his
experiences outside of school, his wishes and feelings, or about his relationships
with his siblings, his mother and her male partners. Despite Daniel being the
focus of concern for all practitioners, in reality he was rarely the focus of
their interventions. Almost every child who has been the subject of a serious
case review over the last 40 years was ‘seen’ by a professional within days (or
hours) of their death.
Simply seeing a child is not protection against harm. The child needs to be
seen, listened to and heard.
Parents need to be robustly challenged about how their behaviours can have a
direct impact on their children, especially when domestic violence and substance
misuse is present. Laming’ comment following the inquiry into the death of
Victoria Climbié about the need for “respectful scepticism” and this is a sentiment
also echoed in the serious case review in respect of Peter Connelly’s death.
Practitioners working with children and their families must remain sceptical of any
explanations, justifications or excuses they hear in connection with the potential
maltreatment of
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Professional Involvement is not the same as engagement. Just because another
professional is involved with a child’s case does not mean that they are
proactively engaged with protecting the child. The danger is that we assume that
if a child has a social worker, they are being protected; or if a police officer visited
the house after a domestic violence incident, the child is safe.
Always check information out – children are best protected when
information is clearly shared across the professionals involved and action
is coordinated. Never assume that someone else is doing something when
you have a cause for concern – two professionals taking action is better
than no one taking action at all.
Neglect is a relationship issue
Neglect (head lice, poor hygiene, weight loss, lack of supervision, hunger etc)
may signal a poor adult-child relationship. All neglect stems from parents
prioritising something else over the child’s basic needs. Professionals sometimes
have the tendency to adopt a ‘wait and see’ attitude and to wait for a trigger
incident before taking action when neglect is suspected.
Ask yourself:
• What is going on in the relationship between the parent and child that is
allowing this to happen?
• Assess where the parents’ priorities lie?
• What individual meaning and value does the parent place on their child?
• How aware is the parent of the child’s needs, personality, strengths and
struggles?
• Put yourself in the child’s shoes – what is it like to be that child’s living
in that household?
Parental participation is not the same as cooperation. Don’t confuse an
apparent willingness to comply with an actual willingness to accept the need to
change. The ‘rule of optimism’ where professionals wrongly assume positive
outcomes for children, is more likely to exist when staff feel under pressure and
this can be very dangerous for children who are at risk. The ‘rule of optimism’
rationalises evidence that contradicts progress – so even where the facts show
that risk is ongoing or increasing, professionals tell themselves that the opposite
is true.
Take the time to stop and critically reflect on your own practice – before
every contact with the child or their family be clear about what it is you are
hoping to achieve. After the contact take a couple of minutes to ask
yourself whether you have met what you set out to achieve.
Also talk to your colleagues to check out practice issues and use
supervision as an opportunity to reflect on what action needs to be
undertaken to improve outcomes for the child.
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Assessment is a Process, Not a One-off Event
Assessment is about understanding the current circumstances for the child and
their family and using this to make decisions about what help is required to
promote improved outcomes for the child. A good assessment and the decision
about the right help required can only be achieved if practitioners understand the
child’s and their family’s history. Practitioners must always use this to inform the
current decision making.
Always look at the historical information – what does it tell you about the
child’s lived experiences so far – how does this impact on the current
circumstances and therefore the assessment for the child? Use this
information together to identify what the next steps are to promote the best
interests of the child.
Always remember that assessments are fluid and should be reviewed when
family circumstances change or new information comes to light.
Assessments should not be carried out in isolation. In order to understand
the child’s experience make sure that you use the information, knowledge,
skills and expertise of partner agency colleagues.
Be clear what the plan is and who is coordinating it – is everyone clear
about their own roles and responsibilities and how they contribution to
achieving the outcomes set out in the child’s plan? Ensure the plan is
regularly reviewed.
See the child…listen to the child…hear the child