Staffing shortages, poor record keeping and a lack of communication were the major factors in failures which led to the murder of schoolboy Daniel Pelka, a report has found.
The report, released today, examines the reasons why numerous workers repeatedly failed to spot the campaign of terror waged upon the four-year-old boy by his own parents before his death.
The analysis was carried out after a Serious Case Review last year exposed a series of errors and failings on behalf of the authorities which dealt with the family.
Coventry boy Daniel, aged four, died in March 2012 at the hands of his mother Magdelena Luczak and his stepfather, former soldier Mariusz Krezolek.
They were both jailed for a minimum of 30 years for his death.
Today, his school, the police, health workers and social care workers all came under fire for their poor working practices and inadequate communication.
The report also found that“questions remain” about why the doctor who saw Daniel did not consider abusemay be one cause of his injuries.
The school came under fire in particular for its poor leadership and lack of training of staff to identify and deal with issues of abuse, which the report states missed the "true significance" of what was happening to Daniel.
The serious case review published last year found Daniel was "invisible" at times, with “numerous”chances to help him missed by all agencies who dealt with him.
Criticisms in the latest report include:
- Inconsistent and poor record keeping
- Insufficient training for staff
- Poor leadership and practice
- Error of judgement not referring Daniel's case to social care
- School nursing service worked with parents - it was "not unusual" for a child not to be seen
- Pressure on referral and assessment due to problems within neighbourhood teams
- Ten social care assessments were audited during the time period - only one was rated as "good"
- Case closed despite evidence showing possibly high risk to children
- No effective supervision
- Team manager did not have sufficient training
- Social worker who assessed Daniel's parents' drugs abuse had not attended special training
- Very poor 'core' assessment
- Delay in entering information meant social workers were unaware of domestic violence reported at the address, including two where Daniel's mother allegedly threatened his father with a knife
- Workload pressures affected staff's capacity to process and respond to information
- Low levels of staffing
- Delay in processing domestic violence notifications
- Haphazard notes kept
- No growth charts
- Ineffective written communication between hospital trusts and community services
- Lack of effective use of the paediatric liaison worker
- Doctor's comments that Daniel's mother's explanation for his injuries was "plausible" was a "major influence" in not pursuing it further
- Limited detail contained within GP's letters
- No easy access to interpreters after 5pm
- Language used was confusing - referring to the children as "safe and well" created an "falsely optimistic" view of the impact on children
- Just two police officers were assigned to review all domestic violence notifications
- An increase in incidents created pressure on this small team
- Delays between notifications and screening
- Report into Daniel's broken arm was not reviewed by a senior manager
- Little evidence of managerial oversight