Daniel Pelka

1. Daniel Pelka Dr David W Jones Named GP for Child Safeguarding Newcastle North and East CCG

2. Note of caution • This subject may raise painful memories or associations • This is not a safe time to share personal memories • If required, seek advice from a professional outside of this meeting, or contact the NSPCC helpline 0808 800 5000

3. The Facts • Daniel Pelka died on 3rd March 2012 – he was 4 years and 8 months • He had suffered abuse and neglect over a prolonged period of time, and had been starved, assaulted, neglected and abused in the 6 months prior to his death. • At time of his death he was malnourished, he had an acute subdural haematoma, an older subdural haematoma, 40 other injuries to his body • His mother (Magdalena Luczak) and step father (MariuszKrezolek) were convicted of his murder on 31st July 2013.

4. Who was Daniel Pelka and why did he die? • Middle of 3 children (others 7 years and 1 year at time of his death) • Family moved from Poland in 2005 • Children had different fathers – the father of the younger brother was convicted of Daniel’s murder

5. Daniel Pelka ‘..very shy, though quite bright and never naughty in school’

6. Domestic violence • First incidence of DV occurred between Daniel’s mother and father in 2006 • Both parents were intoxicated at the time, and Daniel’s mother was pregnant with him • At her booking appointment, Daniel’s mother denied any alcohol misuse. Mr Pelka translated. Any comments? • No concerns identified at Daniel’s 8 week check – but what should we look for? • Daniel’s mother reported ‘a domestic problem’ to her GP who prescribed anti-depressants. She was noted to have two children. She DNAed FU. Any comments?

7. Domestic violence • There were 27 reported incidents of domestic abuse • Police made numerous referrals to children’s social care, but not always, and also made optimistic comments, such as ‘children none the wiser’ • Failure to acknowledge that this was a pattern of family life rather than an unconnected set of isolated events • Failure to recognise and respond to the child protection needs of the children who were living within such a violent and chaotic household • Accepting his mother’s reluctance to receive help, when the needs of the children should have been considered. The need for ‘respectful uncertainty’

8. Moving surgery • Despite several house moves, the family only changed GP once • When notes were summarised, the incidents of DV weren’t noted in the new records • ‘Start Again Syndrome’ was evident How might this be avoided?

9. Arm injury • Daniel sustained a spiral fracture to his left humerus while playing with his 7yo sister and jumping off the sofa in January 2011 • He presented to A+E the day after the incident • The injury was most likely to have involved a twisting mechanism, with immediate pain and swelling • He had other bruising to his body Should the A+E doctors have been concerned?

10. Arm Injury • Daniel’s sister, aged 7, confirmed the mechanism of injury to the police • The fracture was considered ‘plausible and could have occurred in the manner suggested’ • The ‘rule of optimism’ prevailed; ‘a tendency for professionals towards rationalisation and under responsiveness… and to focus on adult strengths to form an optimistic view’ Should we consider ‘balance of probability’ rather than ‘plausibility’?

11. The next pregnancy • Daniel’s mother was admitted with a severe UTI in April 2011, but took her own discharge. • Concerns re social welfare, DV, forensic history, alcohol misuse, and Daniel’s arm fracture were considered, but because CSC had closed the case, no action was taken • She then DNAed 4 ante-natal appointments before disclosing further domestic abuse to the midwife What might have happened next?

12. The secretive eater • In October 2011 a school nurse visited the family home because of concerns re ‘excessive appetite’, and possible speech/language delay and ?learning difficulty • Daniel’s mother also reported soiling and smearing of faeces, and aggressive behaviour What is this behaviour telling us? • Daniel was referred to a community paediatrician, but in the meantime his mother DNAed school nursing appointments, the last of which was 31st October • Two days later the door handle to Daniel’s bedroom at home was removed

13. The starving boy • The school noted a ‘food obsession’ - he ate ‘whatever he could obtain’; • 4-5 pieces of fruit from the ‘fruit corner’ • half the teacher’s birthday cake • other children’s food • food from bins • beans planted in the school garden • raw jelly from the sandpit He was ‘a bag of bones’. They also noticed injuries. How might they have responded?

14. School response • Locked food away • Considered a CAF in January 2012, but decided it wasn’t needed • They got a teacher from another school who could speak to him but he ‘looked down and said nothing’. • The deputy head rang the GP to express concerns How would you respond to such a call? • The GP advised him to tell Daniel’s mother to bring him in for an appointment, which she didn’t do, and this wasn’t followed up. The call details aren’t recorded. She had her own appointment but no link was made to Daniel • The GP ‘remained a passive recipient of information and concerns’

15. The final month • Punishment; • Cold baths • Locked in sparsely furnished room • Starved, beaten • Forced to exercise • Fed salt • Paediatric assessment (10th February 2012) • ‘No wasting but looks thin’ • ‘Growing along the 0.4th centile’ • No communication with the child • ?ASD / ?metabolic problem. Given meds for threadworm What might have been done differently?

16. The final days • On the 1st March 2012, Daniel was seen to take a piece of half eaten fruit from a bin at school, although he was prevented from eating it. • On Friday the 2nd March 2012 Daniel was logged as having an unauthorised absence from school. • On Saturday the 3rd March 2012 a telephone call was made to the ambulance service and Daniel was admitted to hospital at 3.28 a.m. after having suffered a cardiac arrest and he could not be resuscitated. • At his post mortem on the 6th March 2012 the cause of death was found to be a head injury, “almost certainly the result of a direct blow to the head”. Daniel was also considered to be grossly malnourished and dehydrated with bruising over his body for which no natural cause could be identified. (A total of forty injuries were noted). Evidence of longstanding neglect.

17. The invisible child • No record of any professional dialogue with him • No concerted effort to ask him if he was ok • Use of sister to confirm injuries and behaviours (but she was primed by parents) • Failure to interpret behaviour beyond parental explanation • Rule of optimism in growth assessment

18. What can we learn? • Each opportunity to protect a child should be taken • Parental reassurance about DV ceasing and children being unaffected should be responded to with respectful uncertainty • No assessment of risk is complete without direct engagement of the child – child focus needed • Avoid being too incident-focussed - need for an holistic approach • Accurately record facial injuries in children • Think the unthinkable, beware the rule of optimism • Become active recipients of information and concerns