Date post: | 29-Dec-2015 |
Category: |
Documents |
Upload: | liliana-hoover |
View: | 225 times |
Download: | 3 times |
Berkshire West LSCB’s
DANIEL PELKA:
HIS LEGACY
Genogram
Polish immigrants 2005 Daniel born in 2007 – father
Mr P - left family end 2008 Mother in relationship with
Mr K 2008 – mid 2010 Mother in relationship with
Mr A 2010 onwards Adam born 2011
Family History
Family Features
All Polish -Catholic religion English not first language Domestic abuse Alcohol misuse Mother - mental health
issues House moves
Daniel’s life
March 2008 – laceration over eye
Witnesses domestic abuse
July 2010 bruise side of head
Witnesses DV – knives & attempted strangulation of mother
Daniel’s life
Early 2011 – broken arm, multiple bruising
Started school Sept 2011 – issues re obsession with food, attendance, loss of weight.
School noted facial injuries Dec – Feb 2012
Daniel’s life
Ron Lock, Overview Author stated: “if there were such concerns about
the injuries alongside the background of the other concerns, it is difficult to understand why the school did not coordinate these and ensure that a child protection referral was made to CLYP at the time”.
Why do you think this was?
Daniel’s life
Paediatric appt Feb 2012 (aged 4 yrs 7 months)
Wet himself No recognisable words Weight 13.8kg Mother’s explanation Further investigations
Daniel’s secret life - discovered after his death
Anna’s involvement Junk or box roomWithdrawal of foodUse of saltBeing hitBath and nearly drowning
Daniel’s death
2nd March 2012 – not at school. Salt poisoning & not responding – ‘he’ll get over it’
3rd March – cardiac arrest, emaciated & malnourished, bruising & head injury; died ‘direct blow to head’
Missed opportunities
Antenatal bookingsChild development appts27 domestic abuse events
known to PoliceMother’s hospital
attendances Minor injuries to Anna
Missed opportunities Injuries to Daniel noticed
by school & PaediatricianDaniel scavenging for
food at school – school accepted mother’s explanation
Failure of professionals to check information with each other
Missed opportunities
Assessments by social workers
Males were not visibleDaniel only spoken to on
one occasion – issue of him speaking Polish
Professional communication
Impact of movesNot proactiveConfused & ineffective
communicationAssumptionsLack of multi-agency
contributions to social work assessments
Professional communication
Not holisticNot historic ‘Start again’ approach Incident focusedLack of child focusLack of mgt oversight
Police Practice Issues
Need to be child centred at all incidents
Broader checks of situation Always consider the impact
of DV on children Timely notifications to
Children’s Services
Health Visitor’s Practice Issues
Lack of communication with GP’s
Lack of robust attempts to complete assessments
Presumption that no DVNot responsive to
notifications of injury nor DV
Hospital Practice Issues
Identification of impact of mother’s OD on children
Need to question plausibility of parental explanations
Focused on main injury without considering other injuries & issues in context
Rationalisation & under responsiveness
Midwifery Practice Issues
No clarification about mother discharging herself
Not proactive when missed 4 antenatal appointments
Not proactive when mother disclosed DV – inappropriate view that DV is not child protection concern
GP Practice Issues
Failure to alert other professionals
Adult focusLack of proactive
responsesNeed to record on adult &
child records
Probation’s Practice Issues
Failed to up-date assessment when Mr A returned to home – ‘no realistic protection’
Curfew arrangementsRisk assessmentsAdult focus
Children’s Services Practice Issues
Poor quality assessmentsLack of male inclusionDisguised complianceDid not talk directly to
Daniel or Anna
School’s Practice Issues
Disguised complianceUse of interpretersDisparity of viewsNo effective coordination
with school nurses or each other
Poor recording systems
Consolidating & improving practice
Take every opportunityRobustly challenge
explanations & reassurances from parents
Domestic abuse is always a child protection issue
Talk directly to children – ensure no child is invisible
Consolidating & improving practice
Develop understanding of patterns
Write effective and timely records and reports
Physical injuries, especially to face must always be considered as abuse
Consolidating & improving practice
Consider impact of family’s circumstances
Hold own professional judgements
Assess evidence re: ability / willingness to change
Consolidating & improving practice
Don’t rely on family members to corroborate
Don’t make assumptions without checking with colleagues
Always consider child abuse as potential cause
Retain healthy scepticism
Daniel’s mother & her partner, Mr A, were charged
with Daniel’s murder and received sentences of 30
years imprisonment in July 2013.