A fresh review will be published looking into the exact reasons behind a series of failings leading to the death of schoolboy Daniel Pelka. The four-year-old was abused and starved to death by his mother and her partner.
The Coventry and Warwickshire Partnership NHS Trust has looked at "a number of actions" that it needed to take following the death of four-year-old Daniel Pelka, medical director Dr Sharon Binyon said.
Dr Binyon told ITV News: "We know that the number of health visitors in Coventry was one of the lowest in the country, so we have been working with NHS England.
"Since the time of Daniel's death we have doubled the number of health visitors and they will be trebled by 2015."
The Trust has also implemented a new system "whereby when there is a child in the house and domestic violence is reported then automatic reporting goes to school nurses and health visitors as appropriate, but it's also kept electronically on their records."
Prof Eileen Munro told ITV News the Serious Case Review into Daniel Pelka's death is "very frustrating".
Prof Munro, who conducted a review into high-profile abuse cases including the death of Baby P, said the new report "tells you what happened, but it gives you very little idea of why".
She continued: "These were clearly professionals who were concerned about Daniel, they were very actively trying to help him and they failed.
"And I don't get a sense from the review of why they failed - what it looked like, how they were misled, why they didn't see the sadistic torture that was going on - so I find I cannot clearly see what lessons you can draw from it."
Gill Mulhall, the current headteacher of the school Daniel Pelka attended, said if his teachers had been aware of his suffering then they would have "acted very differently".
Ms Mulhall said: "What was proven in the criminal trial is that his mother was a convincing manipulator who fooled many professional bodies over a long period of time by producing a convincing act as a caring parent.
"If we had been aware of the bigger picture of Daniel's life, or had any doubts about his mother, then we would of course have acted very differently.
"What we want to see now are changes where schools are aware of concerns from other agencies which affect our pupils to try and ensure that nothing can ever happen again."
An "alliance of responsibility" should be established so "those people can be held accountable" if another child dies, the Labour MP for the constituency where Daniel Pelka died said.
Geoffrey Robinson, who represents Coventry North West, said the report published today into how Daniel fell through the net "did not solve problems" and that he wants to focus on "getting the system right".
Russell Hobby, general secretary of the National Association of Head Teachers (NAHT) has defended the teachers at Daniel Pelka's school saying that they: "acted properly on the information available."
Daniel Pelka's story will haunt the thoughts of every head teacher. It is an appalling tragedy.
Heads cannot prevent all human evil without treating every parent as a potential criminal but they will always ask whether they could do more and always seek to learn when things go wrong.
NAHT firmly believes that the leaders and staff of Little Heath acted properly on the information available and within the limits of the powers they had been given. It is extremely important to remember that no amount of vigilance by a school can compensate for the wilful misdirection of a deceptive and manipulative individual. Daniel was murdered by his mother and her partner, not by his school.
The Serious Case Review into Daniel Pelka's death has made 15 recommendations for changes to current practice and processes, joint working and training across agencies.
Those recommendations include:
Improvements in the identification and reporting of domestic abuse in families
Better reporting by schools of injuries to children and any welfare concerns
More rigour in social work assessments, recording and challenging parents
The report, published by Coventry Safeguarding Children Board, also highlights the need for more health visitors in Coventry and the importance of health professionals - such as paediatricians - considering child abuse when they assess the welfare of children.
Following the release of the Serious Case Review into the death of schoolboy Daniel Pelka, the National Society for the Prevention of Cruelty to Children has stated that there was 'a basic lack of real action to protect Daniel':
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
– Peter Wanless, CEO of the NSPCC
There must be a culture change from process driven box-ticking to child-aware curiosity; a willingness to question excuses; and a resolve to record and follow through with appropriate urgency whenever we see a child suffering. Professionals must act on their instincts when they feel something could be seriously wrong, not wait until they are certain. Tragically, in Daniel’s case, this failure to see and act at speed may have cost him his life. SCRs like this one have generated enough lessons now – we owe it to Daniel to ensure they are learnt, not filed and forgotten.