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Pelka Serious Case Review: Child protection workers must be given chance to learn from tragic cases

     As the Daniel Pelka Serious Case Review (SCR) is published, the British Association of Social Workers (BASW) has expressed concern that all child protection workers are not being given a chance to learn vital lessons from such tragedies.

BASW has found that Serious Case Reviews are not being properly shared with all child protection social workers, publishing research which reveals that too many social workers are not being given the opportunity to use the findings to improve their practice. 

The survey of BASW members revealed:
• 25% of respondents never get to read SCRs when they are published (just 27% always get to read them)
• 67% say they “only sometimes” get to read the actual recommendations from any Serious Case Reviews (17% say they never get to read them)
• An overwhelming 97% of the 238 respondents said they wanted to see all SCRs stored in one central location so there is continuous, easy access, prompting the Association to publish reports on a designated area of its website

One social worker told BASW: “I often hear about Serious Case Reviews in the press before I am informed by my local authority”.

Another said: “Staff have so little time to read a Serious Case Review given all the competing priorities and information being sent”.

Commenting on the need for better use of SCR recommendations, BASW Chief Executive Bridget Robb said:
“Any child protection professional looking at the details of this case would be deeply saddened at the appalling level of abuse that Daniel suffered at the hands of those responsible for his care and that, ultimately, he was not kept safe from harm.   

"This Serious Case Review highlights once again how it is possible, in rare circumstances, for devious and manipulative individuals to deceive those professionals who are attempting to safeguard the welfare of potentially vulnerable children. 

"It is notable that the SCR avoids apportioning blame, which we very much hope presents an opportunity for all child protection professionals to be given the space to learn from such tragedies.

"Serious Case Reviews have a dual purpose, as a learning opportunity for professionals and as a means of public accountability for a public service.

“We can understand the public perception that when Serious Case Reviews are published there is a surge of publicity but then nothing much seems to be done with the findings.

“Serious Case Reviews focus on what was unique in each case. If they are to be used for professional learning, we also need them to identify a few key messages for everyone. This is not straightforward to do, but essential if they are to have wider use.

“We’d like to see better use of Serious Case Reviews as a learning opportunity for all professionals tasked with protecting children. A range of professionals such as teachers, police, medical staff as well as social workers come into contact with vulnerable children and all follow the government guidance Working Together to Protect Children. We all need to learn the lessons from the SCRs.

“Rather than the current ad hoc distribution of SCRs, where hard pressed staff are expected to read and interpret findings on their own and in their own time, we’d like to see structured briefing podcasts for professionals produced by the authors of the SCRs so that professionals can hear the common messages, and where possible opportunities for professionals from a range of disciplines to come together to discuss the key messages and also to share good practice.”

The Association is also urging that SCR reports each contain key lessons for all professionals involved with children’s services, as opposed to specific recommendations for the organisations involved in a single case.

The SCR into Daniel Pelka found the four-year-old died after "suffering abuse and neglect over a prolonged period of time" at the hands of his mother and stepfather at their Coventry home in March last year, cumulating in a serious head injury.

The report, published to provide lessons from the case to prevent future tragedies, found Daniel's carers "set out to deliberately harm him and to mislead and decieve professionals" about what they were doing.

It highlights a number of missed opportunities to act upon signs of abuse and says there was a lack of a "child focus" to interventions by professionals who too readily accepted parental version of events. Against the backdrop of his mother's controlling behaviour", it says, Daniel "appeared to have been 'invisible' as a needy child".


The SCR, published by the Coventry Safeguarding Board, outlines 14 lessons learned from the case, including urging professionals to "think the unthinkable" in complex child welfare cases and "always give some consideration to child abuse as a potential cause of the presenting problems".

 SeSSSSsssssssSerious Case Review - Overview Report by Coventry Safeguarding Children Board