16:42
Tieng Anh Vui
Opportunities were missed to help a child who was murdered by his mother and her partner after a "terrifying and dreadful" campaign of abuse, a report has found.
A serious case review found Daniel Pelka, four, was "invisible" at times and "no professional tried sufficiently hard enough" to talk to him.
He was starved and beaten for months before he died in March 2012.
The review said "critical lessons" must be "translated into action".
Magdelena Luczak, 27, and Mariusz Krezolek, 34, were told they must serve at least 30 years in jail, after being found guilty of murder at Birmingham Crown Court in July.
'Shocking reading'
The court heard Daniel saw a doctor in hospital for a broken arm, arrived at school with bruises and facial injuries, and was seen scavenging for food.
A teaching assistant described him as a "bag of bones" and the trial heard he was "wasting away". At the time of his death the Coventry schoolboy weighed just over a stone-and-a-half (10kg).
Police were called to 26 separate incidents at the family home, many involving domestic violence and alcohol abuse, the report revealed.
Pelka Serious Case Review
- An independent review set up after Daniel's death in March.
- Chaired by Dr Neil Fraser, a paediatrician from outside Coventry.
- Carried out by a panel including a Detective Chief Inspector from the Public Protection Unit, West Midlands Police, and a manager from the NSPCC.
But it found excuses made by Daniel's "controlling" mother were accepted by professionals who came into contact with the family.
The report said professionals needed to "think the unthinkable" and act upon what they saw, rather than accept "parental versions of what was happening at home".
Much of the detail that emerged in the trial about the level of abuse Daniel suffered was "completely unknown" to the professionals, the review found.
Daniel's father moved to the UK from Poland at the end of 2005 and lived with the family until 2008, when his son was aged one.
The report found Daniel's "voice was not heard throughout" because English was not his first language and he lacked confidence.
"Overall 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," it concluded.
The report said none of the agencies involved could have predicted Daniel's death and found there were "committed attempts" by his school and health professionals to address his "health and behavioural issues" in the months before his death.
But it added: "Too many opportunities were missed for more urgent and purposeful interventions to consider abuse as a possible causation of his problems."
The Children and Families Minister, Edward Timpson, said the report made "shocking reading".
"This serious case review lays bare the missing or misdirected interventions of professionals which should have spotted and stopped the abuse that Daniel was suffering," he said.
Case Analysis
Four-year-old Daniel Pelka was an isolated child with little English who, according to the Serious Case Review, must have existed in a state of anxiety and stress.
Part of the tragedy is that many professionals, from police to teachers to doctors and social workers, were involved with the family, but the report says none actually had a conversation with Daniel about what his life was like.
That lack of focus on the child, along with professionals who too readily accepted what his deceitful mother said and who didn't share information, is a sadly familiar pattern of failures in difficult child protection cases.
The report says it's disconcerting that many of the lessons to be learned from what happened in Coventry, reflect what has already been found in other abuse cases nationally. Its message is that to really protect children, professionals have to think the unthinkable.
Mr Timpson said he had written to the Coventry Safeguarding Children Board asking for a clearer analysis as to why the mistakes occurred.
In a statement Amy Weir, the board's chair, said it had "already been responding to the findings of Daniel's review" and had a "clear timetable" for implementing the report's 15 recommendations.
'Rule of optimism'
The review found school staff did not link Daniel's physical injuries with their concerns about his apparent obsession with food, which his mother claimed was caused by a medical condition.
"Without proactive or consistent action by any professional to engage with him via an interpreter, then his lack of language and low confidence would likely have made it almost impossible for him to reveal the abuse he was suffering at home," the report found.
Important opportunities were missed on two occasions when Daniel was taken to an accident and emergency department with injuries, the review said.
In March 2008, when Daniel was eight months old he was treated for a minor head wound. In January 2011, when he was three-and-a-half, he was taken to A&E with a fractured arm.
The review said the hospital "rightly raised immediate concerns about the [fractured arm]" and that a meeting was held to decide if it was caused by a fall from a settee, as Daniel's mother claimed, or was the result of abuse.
The meeting decided that Luczak's explanation was "plausible".
But the report said the reasons for other bruises found on Daniel at the time, which his mother claimed came from bicycle accidents, were not "fully explored".
"Overall, the 'rule of optimism' appeared to have prevailed in the professional response to Daniel's fracture and to his other bruises," the case review said.
"In consideration of whether his tragic death was predictable or preventable, it could be argued that had a much more enquiring mind been employed by professionals about [his] care, and they were more focussed and determined in their intentions to address those concerns, this would likely have offered greater protection for Daniel,"
Peter Wanless, the NSPCC's chief executive officer, said: "It's important to remember that only two people are ultimately responsible for little Daniel Pelka's death - his mother and her partner.
"However, it's right that we look at missed opportunities and what could have been done differently. Whilst this SCR 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. "
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