General Practitioner Significant Event Bulletin October 2013

Greater Glasgow & Clyde child protection cases

The following is a summary of the Serious Case Review (SCR) commissioned following the death of Daniel Pelka in Coventry. He was born in the UK on the 15th July 2007 and died on the 3rd March 2012.

1. Introduction

1.1 Daniel was murdered by his mother and stepfather in March 2012. For a period of at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister Anna was expected to explain his injuries as accidental. His mother and stepfather were both convicted of murder in August 2013.

1.2 Daniel's mother had relationships with 3 different partners whilst living in the UK. All of these relationships involved high consumption of alcohol and domestic abuse. The Police were called to the address on many occasions and in total there were 27 reported incidents of domestic abuse.

1.3 Daniel's arm was broken at the beginning of 2011 and abuse was suspected but the medical evidence was inconclusive. A social worker carried out an assessment but no continuing need for intervention was identified.

1.4 In September 2011, Daniel started school. He spoke very little English and was generally seen as isolated though he was well behaved. He began to present as always being hungry and took food at every opportunity, sometimes scavenging in bins. His mother was spoken to but told staff that he had health problems.

1.5 Daniel also came to school with bruises and unexplained marks on him. Whilst different school staff members saw these injuries, these were not recorded nor were they linked to Daniel’s concerning behaviours regarding food. No onward referrals were made in respect of these injuries.

1.6 Daniel was seen in February 2012 by a community paediatrician, but his behaviours regarding food and low weight were linked to a likely medical condition. The potential for emotional abuse or neglect as possible causes was not considered. The paediatrician was unaware of the physical injuries that the school had witnessed.

1.7 Three weeks after the paediatric assessment Daniel died following a head injury. The circumstances of Daniel’s death suggested that he had been suffering abuse and neglect over a prolonged period of time.

2. Service Involvement

2.1 Daniel’s father, Mr Pelka, brought the family to the UK from Poland at the end of 2005 and he remained with the family until the end of 2008. A second male then lived in the home from late 2008 until mid-2010, (referred to as Mr A) and then Ms Luczak’s third male partner (Mr Krezolek) moved into the family home shortly after. He became the father of Adam who was born just over a year later.

2.2 All adult family members, including the different male partners, were of Polish nationality, moving to the UK as adults. None of the family had English as their first language.

Chronology of Significant Events

Date / Contact / Notes
March 2006 / Mum registers with GP
November 2006 / First report of domestic abuse / Mum attacked Mr Pelka with knife, both intoxicated with alcohol
Mum pregnant again
08/12/06 / HV receives notification of above / Received by SW March 2007
13/03/07 / Attends antenatal booking visit, denies any alcohol use / Mr Pelka translated at appointment
15/07/07 / Daniel born / HV attends first visit 10 days later, both Daniel and his sister seen – she previously not known to services
15/08/07 / Anna attends OOH service with viral illness / Noted to have lump to head following fall previous day
31/08/07 / Daniel attends 8 week check / No concerns noted
13/12/07 / Domestic abuse incident / Both parents drunk, mum threatening partner with knife. Both children present, go to live with aunt
26/12/07 / Domestic abuse incident / Both parents intoxicated
09/01/08 / Mum attends A&E, intoxicated and has taken overdose / A&E inform HV but not SW
13/01/08 / Parents drunk and arguing in street / Children left with Mr Pelka, police do ‘safe and well’ check but no further action
17/01/08 / HV notified of incident on 13/12/07
29/01/08 / Multi-agency meeting- police, SW and health / Initial assessment to be completed though not recorded in records
01/03/08 / Domestic abuse incident / Both parents claim other assaulted them, police do ‘safe and well’ check, children asleep upstairs
31/08/08 / Daniel age 8 months, attends A&E with laceration to eye- stated rolled from knee while nappy being changed / HV informed
Family move again
06/04/08 / Mum contacts police as Mr Pelka has children and will not return them / Police note mum to be drunk and uncooperative. Referred to SW, initial assessment suggest both parents acknowledge domestic abuse impacts on children and have put strategies in place to minimise risk- case closed
28/05/08 / Move house
June 2008 / Anna DNA 3yr check
17/08/08 / Mum calls police / On arrival mum intoxicated, dad calm and sober. No further action taken.
HV informed 3 weeks later
01/09/08 / Mum attends A&E with overdose and alcohol use. Attended with 2 people she did not know / Assessed as being suicidal and needing to be admitted. Drs aware of children at home and contact SW.
Mum takes own discharge, no record of SW response
15/09/08 / Multi-agency meeting to discuss domestic abuse incidents / No reference to previous assessment, agencies to monitor
09/11/08 / Attends ante-natal booking visit, 12 weeks pregnant / GP notes HV has referred to SW.
Main reason for referral was lack of money and pending eviction, history of domestic abuse noted
19/11/08 / Mr Pelka contacts police,(now separated from mum), mum had arrived at house as had been arguing with new partner Mr A / Mr A had been drinking and smashed up home, no further action by police as accommodation belonged to Mr A
24/11/08 / Domestic abuse incident / Mum and Mr A drunk, violent towards each other, mum holding Daniel when police arrive. Mr A arrested
SW and HV informed (on 09/12/08)
Btwn 13-17/12/08 / Incidents of drunkenness and shouting noted at family home / No further action
07/01/09 / Neighbours contact police re mum and children crying / Mr A found in garden with knife, arrested and charged
11th and 17th Jan 09 / Both mum and Mr A reported to police re drunk in family home / No on-going referrals from these incidents
16/01/09 / Joint screening meeting* / No recorded outcome
22/01/09 / Following team meeting, HV refers to SW incidents from November 08 / SW visit, no further action, mum able to protect children
12/02/09 / Move house again / In rent arrears
16/02/09 / Mr A convicted of being in possession of knife / The probation assessment of Mr A described him as posing a medium risk to his ex-partner and highlighted the potential risk to children due to the environment of domestic violence
08/03/09 / Mum intoxicated, domestic abuse incident / Children noted to be ‘safe and showed no signs of distress whatsoever’
Police refer to SW
25/03/09 / Joint meeting btwn police and SW to discuss 4 incidents of domestic abuse that had occurred in previous year- the last being noted as 07/01/09 / Decision to hold a strategy meeting-a multi-agency meeting to decide whether child protection processes are needed to protect children - took 6 months to occur
23/04/09 / Mum has a miscarriage
09/05/09 / Mum reports to police Mr A was beating her / Mum uncooperative when police arrive – children noted to be present
1-2/06/09 / Reports of fighting in house / Mum’s sister reports too much drinking in house and children crying
No offences reported to police
23/07/09 / Mr A re-sentenced due to breaches of community order / Curfew of 8m-8am imposed- made at address of mum
27/07/09 / Domestic abuse incident / Police called, Mr A drinking all day, confrontation btwn adults witnessed by children
28/07/09 / Mr A returns to family home- breaks window, mum recalls police / Mum has minor facial bruising, police take her to stay with her sister
SW and HV informed
14/08/09 / Joint Screening meeting- held to discuss incidents on 8th March 09. / Police note need for strategy meeting.
Offender manger contacts SW re domestic abuse incidents but informed case closed and no concerns
18/09/09 / Domestic abuse incident / Each alleges other assaulted them, both arrested, mum intoxicated.
Mum claims to be pregnant, seen at hospital- negative pregnancy test
05/10/09 / SW visit home- children and mum not seen
12/10/09 / Further joint screening meeting / Noted strategy meeting still outstanding
23/10/09 / Strategy meeting held / SW to undertake core assessment
30/10/09 / Offender manager of Mr A contacts SW again / Told SW visiting following week and would liaise back if any concerns
05/11/09 / Domestic abuse incident / Mum states ‘ex-partner’ had been intoxicated and had tried to get into family home
06/11/09-08/12/09 / Core assessment completed / Due to belief Mr A was out of house, assessment concluded children were safe in mum’s care and case closed 07/01/10
17/11/09 / Probation assessment review / Manager asks worker to follow up on recent visit by SW to family home- no record of this
13/01/10 / Mr A further conviction / One months imprisonment
Nov 09-Jan 10 / Move house / Defaulted on rent
Jan -March 10 / Numerous occasions of Anna’s low school attendance noted
March 2010 / Move house and change GP
02/03/10 / Mum calls police- Mr A attended house and threatening her / Mr A later arrested
Police refer to SW but informed NFA
25/03/10 / MARAC meting held (domestic abuse multiagency meeting) / Mr A following mum, has weapon
HV to provide support
06/04/10 / Mum reports harassment and threats from Mr A / Mr A again arrested but insufficient evidence to progress
SW state assessment will be completed
02/05/10 / Domestic abuse incident- from new partner Mr Krezolek (Mr K) / Children heard crying in bedroom
Mr K arrested for assault though mum refused to give statement so charges dropped-finger injury
Referral to SW
Mum attended A&E next day- fracture to finger, told Dr she caught finger in door frame when door slammed during incident previous day
June 10 / SW unable to locate family / Case was closed by 01/06/10
July 2010 / Family return to Coventry / New partner now Mr K
05/07/10 / Home visit by HV
Daniel had bruise to side of head- ‘fell over’ / Mum told HV she had seen GP for injury- no record of this
HV noted spoke little English
HV discussed domestic abuse with mum
21/07/10 / Mum attends GP- Describes experiencing a ‘domestic problem’ / GP diagnosis of depression and prescribes anti-depressants and to review in 4 weeks, no record of follow up appointment
08/08/10 / Domestic abuse incident / Knives evident in incident btwn mum and Mr K. Mr K drunk, she describes losing consciousness and children witnessed whole incident.
Mr K arrested, later released with no charges and returned to family home.
Mum alleges Mr K has raped her ‘many times’
08/08/10 / Mr K alleges mum could not live without cannabis or amphetamines / This concern not formally recorded and no further action
10th, 14th and 18th August / Telephone calls to mum from police to check all was well. / Mum advises she has allowed Mr K to return to the home.
21/08/10 / Mum involved in RTA as a pedestrian / Not badly hurt but hospital records read ‘drinking+++’
September 2010 / Anna starts new school
Oct/Nov 2010 / Anna’s attendance at school a problem
14/11/10 / Mum attends A&E with lacerated arm / Claims fell on broken glass
27/12/10 / Domestic abuse incident / Both adults intoxicated and fighting in presence of children. Neighbour reports incident. Police note ‘children none the wiser’ no SW referral made.
06/01/11 / Daniel attends A&E with spiral fracture to left arm, also multiple bruising to arm plus to shoulder and lower stomach / Daniel noted to not interact well with mum and Mr K at examination. Explanation for fracture given as had been jumping from the settee and fallen to floor. Late presentation of injury. Noted that significant twisting required to produce this fracture and ‘swelling and pain would have been evident yesterday’.
06/01/11 / Hospital refer to SW / Cause of fracture not clear and delay in presentation. Police informed. Anna confirms mums account of injury.
07/01/11 / Child protection meeting held / Consultant paediatrician after further consultation with colleague states mum’s account could be plausible for injury.
Further assessment suggested.
17/01/11 / Daniel returns to hospital to get arm manipulated under anaesthetic / Weight recorded a 15.2kg
23/02/11 / Core assessment completed / Case closed by SW by late May 2011. Concludes domestic abuse no longer an issues, both adults had ceased drinking as mum currently pregnant. Also noted about to be evicted due to rent arrears and not entitled to housing benefit. Advised to attend CAB.
09/02/11 / Mum attends ante-natal clinic / Mum states no drug or alcohol use.
16/02/11 / Joint screening meeting / No outcome recorded
07/03/11 / HV receives three domestic abuse notifications from 06/11/09, 08/08/10 and 29/12/10
March 2011 / Move home
04/04/11 / Mum seen at ante-natal clinic- 19 weeks pregnant / Tells staff partner putting emotional pressure on her to have a termination. Denies any domestic abuse. GP letter states significant social issues.
08/04/11 / School contact mum re Anna’s attendance
26/04/11 / Mum attends A&E with severe UTI / Urged to be admitted but told staff she had ‘no money or childcare’ declines offer to contact SW for support.