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Failures In Child Protection A Case Study

But yesterday's inspection report found that social workers at Haringey tended to have heavy and unmanageable workloads and did not have time to deal with cases properly.

Some were only told about new cases via email, without any discussion with their managers. Miss Ward had 50 per cent more cases than she should have done, it was claimed, and she struggled to cope.

As part of the child protection plan, there should have been a comprehensive case file on Baby P which was made available to all the agencies involved in his care.

But poor communication - with agencies working in "isolation" - meant that although Baby P was seen more than 60 times by social workers, police and doctors, no one had a grasp of the terrible abuse he was suffering.

Injuries were explained away to social workers as accidental - falling into a chimney place, for example - while other meetings and visits were never written up at all.

Yesterday's inspection report found that in some child care cases at Haringey, the hand-written notes on file were so illegible they were impossible to read.

It also found that police files, as well as social care files, were disorganised with dates in the wrong order. When a police visit was made, ranks of officers involved were rarely written down.

The inspection report criticised the way children were assessed in the borough and concluded that there was "repeated failure" to take into account a child's history.

Consultant paediatrician Dr Sabah al-Sayyat, who failed to spot Baby P's broken probably spine two days before he died, claimed she had not been told there were any child protection issues.

She did not examine the child properly because he was "miserable and cranky".

Four days before he died, Miss Ward visited Baby P at home and saw that his face and hands were covered in chocolate and nappy cream.

Although she asked his mother to clean him up, she did not stay to see him washed. Had she done so, she may well have spotted at least 15 injuries to his face and head.

The inspection report found that many children at risk were not spoken to properly about any suspected abuse and often were not on their own during any conversation.

Ed Balls, Secretary of State for Children, said one of his biggest concerns was that there was a failure to allow children to "speak up without fear".

Miss Ward was not alone with Baby P, nor did she do more than speak only briefly to him in the presence of his mother on her last visit before he died.

When she saw the child sitting in his pushchair, she described him as appearing well. "He smiled when I spoke to him," she said. Four days later he was dead.

What Miss Ward - and the multitude of people who had seen Baby P - failed to realise was that he had known nothing but violence in the last eight months of his life.

He had been treated worse than a dog and lived in indescribable squalor. On the night he died, he had been punched so hard in the face that he had swallowed a tooth.

It was one of many acts of violence carried out on the child, but the inspection report found that although police generally attended cases where sexual abuse was suspected, they were not so consistent where there was physical abuse.

One of the most worrying aspects of Baby P's case was that he was seen by so many different people. In a dossier of evidence released last month, there are lists of different doctors, social workers, health advisors and police officers who dealt with him.

The inspection report found that there was a lack of long term employees in Haringey's social care teams - agency staff currently make up 51 of 121 social worker posts.

The number of police involved in child protection in Haringey - including child abuse investigation teams - was also found to be inadequate.

By the time his lifeless body was discovered on August 3, 2007, Baby P had been on the child protection plan for nine months.

Secretary of State for Children Ed Balls, said the fact that a child had died despite being on the "at risk" register was the "most serious failing of all".

Child protection plans were heavily criticised in the inspection report for being disorganised with little analysis of the child and no clear decision-making.

The inspection report went so far as to suggest that such plans did little to make a child safe.

Even after death, Baby P's case proved another example of failure and short-comings.

The Serious Case Review ordered in the light of his death was condemned as inadequate yesterday and had missed "important opportunities" to make ensure the same tragedy never happened again.

The failing prompted Mr Balls to call for a new Serious Case Review into Baby P with an independent adjudicator.

Only now, 15 months after he died alone and in excruciating pain, does the toddler's death mean anything.

Teachers, health professionals, social workers and police officers treated four-year-old Daniel Pelka as if he was invisible, failing to prevent his mother and stepfather from murdering him after a campaign of torture and starvation, an independent report has found.

A serious case review published on Tuesday could find no record of any conversation professionals had with Daniel about his home life, his feelings or his relationships with his mother and her male partners.

Daniel's first language was Polish and the report suggested that this could have been a problem. It said: "Of particular note was that without English as his first language and because of his lack of confidence Daniel's voice was not heard throughout this case."

At times, the review concluded, Daniel appeared to have been "invisible" against the backdrop of his mother's controlling behaviour. Professionals failed to act on "what they saw in front of them" but accepted parental versions of events.

The report said Daniel's "traumatic abusive experiences" during the last six months of his life were "shocking", adding: "He must have felt utterly alone and worthless for much of that time, being the subject of his mother and stepfather's anger and rejection. At times he was treated as inhuman, and the level of helplessness he must have felt in such a terrifying environment would have been overwhelming. The extent of his abuse, however, went undiscovered and unknown to professionals at the time."

Daniel's mother, Magdelena Luczak, 27, and her partner, Mariusz Krezolek, 34, both Polish nationals, will serve at least 30 years in prison for Daniel's murder. During a harrowing trial a jury heard that Daniel looked like a concentration camp victim when he died in March 2012. The court was told that he was subjected to torture including having his head held under water until he passed out and being force-fed salt. He was kept locked in a filthy box room at home in Coventry and was systematically denied food before dying after receiving a blow to his head.

The review team also accused Daniel's school of having a "dysfunctional" approach to children's safeguarding issues, highlighting that teachers had noticed injuries to his face and had locked away pupils' lunch boxes to stop him stealing food, but had not taken effective action to help him. Health professionals and social workers had been too quick to accept that injuries needing hospital treatment including a broken arm and a cut over the eye were the result of accidents – though it also said they were under pressure because of high workloads and understaffing. The report criticised a community paediatrician who saw Daniel a month before he was murdered for putting his weight loss down to worms rather than possible child abuse.

In addition it emerged in the report that police attended Daniel's "chaotic" household almost 30 times in response to reports of domestic abuse in the six years before his death and it suggested officers could have done more to make sure he was being well treated. "In many respects the response by the police was not child-centred," the report said.

On Daniel's school, Little Heath primary, the report said staff did not pass on concerns to police or council child protection officials when the boy came to school with bruises and other marks on him. The school did not appear to link the injuries to his obvious hunger. "The system within the school to respond to safeguarding concerns was therefore dysfunctional at this time," the report concluded.

The author of the serious case review report, Ron Lock, said: "If professionals had used more inquiring minds and been more focused in their intentions to address concerns, it's likely that Daniel would have been better protected from the people who killed him."Peter Wanless, chief executive officer of the NSPCC, said: "Too often people failed to look at Daniel like they would their own child." Maggie Atkinson, the Children's Commissioner for England said: "Far too many opportunities to intervene to stop the abuse Daniel experienced during his short life were missed by those around him who had a duty to protect him."