Sample Social Work Paper on Serious Case Review of Daniel Pelka


Assessments, according to Hawkes (nd) are integral to social work. They are embarked on by social workers to gain access to resources including social grants. As highlighted by the scholar, they are used by court panels and managers to aid in the decision making process, subsequently, having a profound and lasting impact upon children and their families; thus comprehensive and adequate assessments are paramount to the success of any social work. The primary subject of this review is Daniel Pelka who was murdered by his step father and mother in March 2012. A number of factors characterized his death including malnourishment, acute subdural haematoma and subsequent mild subdural haematoma of several months. Daniel was also a subject of continued harm and neglect. Different agencies made a number of enquiries into this case that led to his death, regrettably, no significant action was taken until it was too late. Subsequent to his death, the Coventry Safeguard Children Board commissioned a SCR raised many questions concerning the mismanagement of his case, which are however not as important as understanding how it all happened in order to prevent same incidences in future. On that note, while looking at the Coventry safeguarding children board serious case review for the case, this essay aims to examine critically the process and the purpose of assessment in social work. It will also consider how effective the process should be when analysing risk, need and ongoing intervention. It will also highlight the importance of applying theory and research to inform ongoing analysis of risk, need and intervention.

Assessment of risk and need

Section 17 of the Children Act highlights ‘need’ by stating each local authority has the obligation to children in need and provide universal services in order to meet them (Hunt, Macleod & Thomas, 1999). On a personal level, a child is in need when “he is unlikely to maintain or reach a satisfactory level of health or development/ or his health or development will be impaired without the provision of services/ or he or she is disabled” (DoH, 2000). In such instances, within the meaning of section 17, local authorities are supposed to assess the needs of children who are assumed to be in need. The concept of need has however been disregarded by several scholars by claiming that it is vague. Others on the others hand claim that local authorities lack the needed resources to take on the extensive task of identifying collective needs. The Framework for the Assessment of children in Need and their families suggests a three domain framework for assessment of needs in children that includes assessing their developmental needs characterized by education, health, family and social relationship among others. The second entails the capacity of caregivers to respond efficiently to such needs and thirdly, the impacts of the broader family and various environmental issues on children and parenting capability. Under the risk concept, even though there is no definition of risk, within the 1989 Act, protection is under significant harm, which requires local authorities to make or cause to make enquiries in cases when they have a sound cause to suspect that a child is suffering or likely to suffer significant harm. Herein, they can decide if they should take appropriate actions to promote or safeguard the welfare of the child. Under s. 31 of the 1989 Act, working together to safeguard children highlights that harm means impairment or ill-treatment of the development of health of a child. Thus risk assessments are normally done once harm has been identified.

As mentioned, the assessment in social work, forms the most important element. Three different models have been highlighted including the questioning model, the procedural model and the exchange model, which do not take into account the impacts of structural disadvantages, for instance ethnicity or race, leaving little room for social work values such as empowerment supposing that social work holds a domination in knowledge. The procedural model in the current systems is currently not used for child protection for anything more than service allocation and once services are allocated, detailed assessments follow.

Indeed, Daniel was both in need and at risk. According to the Children’s Act, his conditions were supposed to be accessed by local authorities, which according to the Coventry Safeguarding Children Board serious case review, were done. According to Wonnacott & Watts (2014) by the time the first initial assessment was done, seven domestic violence incidents had already taken place, including that which Daniel’s mother threatened his father a knife. The social worker who conducted the assessment was unaware of the prior incidents due to delays in information screening and therefore approached that assessment in line with the guidance which required the initial assessments to be brief. Luckily, the move from compliance to a learning culture according to the Munro review following this SCR will allow individuals working in child protection services to have exercise professional judgement in deciding the better ways of helping a child. Had the latter been implemented, the social worker could have maybe made the initial assessment thorough and therefore forwarded Daniel’s case to child protection services. The second and the core assessments, were of poor quality, in addition, the core assessment relied on the information from his mother and little or no information from the local authorities (Wonnacott & Watts 2014). One important thing to note is that the knowledge and skills of the persons carrying out effective assessment was not a requirement and this was not identified during the supervision and the management process. The social worker who conducted the core assessment was newly qualified and the manager was not part of the team. This fact brings as to the concept that social workers need to be equipped. According to Smith & Donovan (2003) children, protecting without question, is the most demanding public service that requires good use of authority, inquiring minds and great skills in making sense of what life is really like for the children involved. The second assessment could have been a pivotal moment for the cases since there was the opportunity to realize that the child was being abused physically. It took place after the investigation into the spiral fracture of the child’s, which would have led to the continuation of the section 47 inquiries. According to Humphreys & Stanley (2006) the skills and knowledge required to undertake social work assessments where there is presence of neglect or abuse are paramount. As highlighted by Wonnacott & Watts (2014) the social worker had little training, which forms one of the key aspects in such cases.  Working together group created a strategy that discussions should be conducted in the presence of sound cause to suspect that a child is likely to suffer or suffering from significant harm. The major function of the strategy discussions is to decide whether section 47 enquiries should be conducted and whether a core assessment should be undertaken. In addition, a plan should be designed on how such assessments should be conducted. In Daniel’s case, it was decided that there was no need to initiate section 47 enquiries but a core assessment was to be conducted under section 17 (which was mentioned previously).

Relevance of SCR and the role of Ofsted

One important thing to note that without SCR, it would have been difficult to pinpoint what went wrong in the case study. According to (Sinclair & Bullock, 2002). SCR function as a basis for altering the way social systems function for the benefit of communities on a longer term perspective. Information provided by the SCR help inspectorate bodies including Ofsted to help improve the education and the social systems (Sinclair & Bullock, 2002). Previously the expanded Ofsted lost its specialism elements associated with its precursors at both operational and senior levels. Its split to form the inspectorate for Education and for Children’s care ensured that its services were more effective. The present board emphasizes on the quality of social work services practice and the effectiveness of help. In addition, the children’s care inspectorate ensures that its practitioners are experienced and can command the respect of social workers and childcare professionals. The board also ensures that their workforce can promote and support improvements along with regulating for statutory purpose. Ofsted by emphasizing quality of practice and effectiveness of help lead to the provision of better services. It is clear that its previous expansion had reduced its rate of specialism since if the opposite were true, then some of the avoidable issues within the case study would not have occurred. Nonetheless, currently it is putting pressure on local authorities to enhance their services, following the death of various children in the recent past.

Clearly, SCRs play important roles in changing the social systems. According to Ofsted Manthorpe & Martineau (2010) in the recent years, SCR and SCRRs base on a number of vital points including focussing on good practice, ensuring necessary action takes place, implementing the assessment process effectively, valuing challenge, effective multiagency work and utilising all resources, most of which are evident in the present case. The report, along with its precursors investigated thoroughly the elements concerning SCRs, with the main points of the Ofsteds revolving around children, their families, incidents and lessons learnt from the SCRs. The lessons learnt, as previously mentioned are supposed to improve the risk management process of harm to children rather than identify the most vulnerable children. In addition, individuals are supposed to learn from the experiences rather than blame or discipline the individuals involved. In this present SCR however, it is clear that some of the lessons were not clearly learnt. For instance, some of the vital points of SCRs including effective multiagency work, ensuring necessary action takes place and implementing the assessment process effectively characterize this case. This fact, however, questions the function and the purpose SCR. Another important factor to highlight is that according to (Bandon, 2009) SCR have the power to influence public opinions and shape the attitudes of individuals. In addition, the influence of the media on masses can greatly influence the opinions of people. This was evident in the case of Baby P, as some of the ministers had to shift sides

Several approaches have also been proposed to managing reviews, however, as Manthorpe & Martineau (2010) point out, they do not address the wider question such as the shape and culture of the safeguarding systems. Every children’s risk analysis dictates that abuse tends to be with the human condition and that it is found in different forms in all societies. Thus, no amount of reflection of why poor practices took place can eliminate the risk to children, even though, according to statistics, the SCR are said to reduce risk and improve the lives of children. However, other cases have proven that risk results from individual characteristics and cultural influences. The lack of willingness of some members in our societies to confront to cultures that condone and in part celebrate the aggressive sexual behaviour of men and negative stereotyping of women suggests that some of the social injustices will continue. As highlighted by Manthorpe & Martineau (2010) history shows that the political and social attitudes of individuals remain ambivalent about intervention in family life and the respective children and parents creating an uncertain environment for practitioners and SCR authors.

Why things were missed

Like in other cases, the present SCR highlights why some of the case’s important factors were missed. To begin with, poor communication between the police force and the other agency affected the assessment process. Consequently, the service worker making the initial assessment was unable to detect the severity of the situation. This factor can however be attributed to the overloaded systems where the processing of information is slow. One important factor to highlight had the systems been digitalized maybe the first worker, who was experienced could have forwarded the case to the child services.  Another factor involved is poor use of words. As highlights Bonvillain (2013) communication styles, the use of language and style are equally important when communicating information to make sure that the correct emphasis is put on the important issues discussed. The use of “safe and well”, with regards to the children in the risk assessment form provided a falsely positive view of the condition of the children, which was also based on brief encounters that the officers had with the children. In addition, the use of the word ‘plausible’ by the doctors had a key effect on the choice of not to pursuing section 47 enquiries. As highlighted by Wonnacott, Watts & Safeguarding (2014) if the doctors would have used both non-accidental and accidental, it could have been more obliging. Another important concept that underlines the importance of communication is the fact that there was ineffective written communication between the community services and the acute hospital trust. According to Wonnacott, Watts & Safeguarding (2014) several reports, for instance, Daniel’s broken arm report were not conveyed to the health visitors, which would have otherwise raised a certain level of concern and prompted a visit. The health department inability to link emerging issues about the unborn baby and other children within the family during the pregnancy of Daniel’s mother was also highlighted. Since information was lost, the health visitor failed to attain an overall picture of the circumstances within the family.

It is important to note that according to Arnold & Boggs (2015) effective communication depends on the relationships of the individuals involved. For instance, the school nurse, who was very experienced failed to reach out to Daniel since she was not assigned to the school, hence was unable to have day to day relationships with individuals such as Daniel’s teacher (Wonnacott, Watts & Safeguarding, 2014). This case also highlights inadequate leadership and practice and according to Wonnacott, Watts & Safeguarding (2014) a disjointed child protection system. For instance, as evident, different individuals were involved in different aspects of child attendance, protection and wellbeing. Due to poor practices, however, even though the professionals functioned effectively in their work, ineffective communication and lack of a formal mechanism for gathering information hindered the creation of a case, which would have otherwise saved the child. The use of poor language styles used by professionals is not only special to this report a SCR conducted by the Derbyshire Safeguarding Children’s Board, which investigated injuries to a certain child highlighted that the inadequate style of reporting by a paediatrician led to a lack of understanding on the kind of danger the child was, which also raises the question as to whether, SCR are fully serving their intended purposes.

Secondly, the business of everyone’s work worlds, differing priorities and less than fulsome appreciation of the roles of others impedes the sharing of knowledge (Bridges, et al 2011). Different agencies should work come together and function as a single entity since as pointed out by Lesley Bainbridge, Louise Nasmith & Wood/ (2010) the interprofessional team based approach can improve the sharing of information, motivating and worthwhile among other factors. The authors also claim that a team based approaches can lead to early interventions, increased involvement and consequently improve the outcomes of the team services. Team based approaches also decrease the stigma of specific engagement from professional teams, including the police and social services (Hepworth, et al, 2016). Payne (2015) however, claims that despite the benefits, interprofessional teams may not be as collaborative as anticipated, which characterizes the present case and other social work settings. Padgett (2016) also points out that in some cases, it leads to confusion over professional responsibilities, and as previously mentioned territorial conflicts and may also increase the work load of others. Increased work load implies that there will be constraints which will affect the contact consequently leading to poor communication. These factors also characterize the present SCR however, one striking feature is that several agencies, including the police and the health department slowed down the release of information which negatively affected the case. Generally, ineffective inter-professional communication has a negative effect on collaboration, which consequently obstructs the negotiation process. In person centred care decisions, according to Payne (2015) all team members should be actively involved, which is only achieved through effective communication. Collaboration is often effected also with timely sharing of the relevant material, which also speeds up the referral process, which also presents opportunities for early intervention. In a research conducted by Grinnell & Unrau, (2010) the authors discovered that delays in communication can lead to assumptions that the situation is not as dangerous as initially perceived. In the case of Daniel, the delays in presenting the documents to the relevant professionals, could or might have led to the assumption that his case was not severe which unfortunately led to his death.

Another important theme that is clearly highlighted within the SCR is poor leadership. To begin with, the fragmented system in his school did not make it possible for the assigned school nurse to access the Daniel’s situation. In this case also, the different agencies working on such cases should define clear leadership since according to Lesley Bainbridge, Louise Nasmith & Wood (2010) effective leadership can aid in the collaboration process enabling the team to work jointly and effectively. In the UK, for the benefit of children, the UK legislative framework dictated that professional work together. This, however according to Payne (2015) was a way that previously brought division in social services. Its importance was nonetheless, highlighted by the professional failure to share pertinent information and collaborate in two highly profiled cases that led to the deaths of Baby P and Victoria Climbie. Effective leadership, as previously mentioned can actually help in enabling multi-professional teams to work together basing on the team dynamic concept. According to White et al (2010), teams evolve in different stages that are sometimes characterized by a period of inertia where team members experience a feeling of failure and loss of shared sense of opportunity. A team leader, herein, can prevent this from happening through timely intervention. Team leaders also ensure the engagement of other team members during the practice, which in this case could have hastened the delivery of the necessary reports from the police officers regarding the home situation of the victim. In this case, it is possible that the lack of specialism by Ofsted reduced the pressure that had initially been placed on local authorities, which contributed to poor quality assessments.

With regards to communication and collaboration, another theme that presents itself strongly includes language barrier. As pointed out by Fillmore Kempler & Wang (2014) language differences form one of the core problems encountered by social works in the present multicultural society. From the onset of social and health education, these professionals develop a repertoire of skills, including active listening skills, cultural awareness and sensitivity and relationship building among others. Nonetheless, due to forces such as international networking, worldwide globalization and global transmigration among others, the chances that a social worker will have clients who are multinational, multilingual and cultural are very great, which tests the ability of these professionals to meaningfully interact with their clients. Even though in the recent decades, these professionals have made great strides in the cultural competence area, according to Fillmore Kempler & Wang (2014) they may only have scratched the surface of developing their skills in the area of effective linguistic communication in the populations that they serve. Multilingualism offers both challenges and opportunities for social workers to improve their strategies for assisting those in need. Research indicates that among other victims, individuals lacking Basic English skills are at an increased risk of deficient interventions and medical errors among other issues. The SCR documented that Daniel spoke little English. On several occasions, when the authorities wanted to reach out to Daniel, they depended on both his mother and his sister, which, according to Mehlman, et al (2010) is a poor practice specifically in suspected abuse cases since it raises the risk of collusion, errors and omission among others. Since Daniel’s mother was the abuser, the latter proves to be true, thus as highlighted by Wonnacott, Watts & Safeguarding, (2014) the decision making process only focussed on the needs of the mother rather than those of Daniel. In this case, however, language barrier cannot be labelled as one of the major sources of failure in the social work services from within the UK, they could have easily located a polish speaker who could interpret Daniel’s messages effectively.

Importance of theory in social work

Another aspect of the SCR is the fact that the professionals involved lack essential skills to intervene effectively into the case. As stated by Robinson & Cottrell (2005) it is very essential for social and health workers when conducting assessments to possess extensive knowledge of their clients; aspects such as emotional and cognitive behaviour, economic and social interpersonal relations and education should be clearly examined. It is worth noting that even though other factors may seem irrelevant, the failure to recognize them may result in invalid or pointless assessments which in some cases may be harmful. This SCR presents a clear picture of the mentioned facts since had the professionals involved taken a more serious and deeper analysis of the case, then they would have gotten a clear picture of the circumstances in his life, which would have resulted in an early intervention that could have prevented his premature death. The Holt, Buckley & Whelan (2008) research also provides a similar view of assessment. The authors, with regards to domestic violence state that children should always be regarded as the focal point of any assessment. The authors also stress the significance of holistic and integrated approach together with good observation skills, which present a clearer focus on the outcomes of the assessment, which are majorly child centred. In this case, however, evidently, the victim was never placed at the centre of any assessment until it was too late. While much emphasis was placed at his parent’s alcohol abuse and issues relating to domestic violence, as evident, small emphasis was placed on the wellbeing of the children. As it is highlighted within the SCR, no agency involved understood the risk in which the chaotic family life had on the children. Even though more than twenty separate cases required the attendance of a police officer, too much emphasis was placed on the presenting problem which in all instances was their mother and her partners. The authors also highlighted this issue by claiming that in most circumstances, underneath the presenting problem, there is always something and therefore, while dealing with the problem at hand, it is important to deeply assess its impacts and causes by going beyond what is initially presented. In this situation, however, as mentioned, no attempt was made to go beyond the presenting problems. On the other hand, if much emphasis could have been placed on the children rather than the parents, then the social workers could have been able to detect signs of abuses to detect whether the children’s failure to highlight the abuse was based on the attachment theory, which focusses on the bonds formed between children and parents (Mikulincer, Shaver, & Pereg, 2003). Unlike children born in good families, neglected children or those suffering from abuse can detach from their parents, which, according to Mikulincer, Shaver, & Pereg, (2003) is characterized by disruptive behaviour. Even though the assessment showed that they had an active relationship with their mother, if the team were more engaged, more knowledgeable and more focused on the children, they would have recognized that  the children exhibited disorganized attachment and indicators of neglect such as head bang and repetitive play among others (according to the SCR report). In addition, if the social services would have focused on the family as a system, in accordance to the family systems theory, then they would have been able to detect his condition. Furthermore, even if the child did not exhibit signs of abuse, basing on the resilience theory defined as the capacity for successful adaptation in the face of adversity, they would have still made enquiries since as Eckenrode, et al (2000) highlights, in homes characterized by domestic violence, alcohol abuse and unstable partners, it is likely that the children are exposed to neglect.

A very important lesson highlighted here is that assessments are very significant and as social and health workers having the necessary skills and knowledge to conduct an effective assessment can make a huge difference. In addition, the application of theory to inform practice is also highlighted herein due to its ability to provide all-encompassing theoretical context in which the professional involved can make sense of what is going on and why it’s happening. Nevertheless, even though the latter holds, in the real sense, social and health workers in most cases face significant difficulties when conducting assessments. Chan et al (2000) noted that formalities such as paperwork, excessive bureaucracies and the adherence to rules among other factors in most cases leaves social workers in desperate situations which affect their inability to function effectively. In this SCR it is evident that bureaucracy triumphed over protection, common sense and supervision, which highlights the fact that social and health workers in such cases should recognize that their primary concern is a child’s welfare.

The primary function of any assessment is to understand the situation of the victims involved otherwise the process would be meaningless. With that said, even though assessment was conducted herein, according to the SCR report, no attempts were made by the professionals involved to understand the situation of the child. No one actually observed and studied the victim, which as mentioned before could have greatly helped with the case. In the assessment of social needs, as highlighted by Royse (2007) the main function of observation is to understand and facilitate communication with the child which leads to the generation of information. To warrant that the victims’ needs are fully met, it is very important to communicate with them. Regrettably, no one communicated with Daniel or rather took an opportunity to observe him so that they can understand him. In order to conduct their work effectively, as stated by their professional board, social and health workers should learn to observe and communicate with the victims to make sense of their circumstances. Apart from good assessment skills, social and health workers need to have adequate knowledge in their field and try to think outside the box in different circumstance. Despite the reports that they received from Daniel’s parents, the fact that he always seemed invisible and his poor language and social skills clearly indicate that something was wrong with the kid. And as mentioned before his head bangs also indicated that there was something wrong with him, which could have prompted an assessment had the social workers been so reasonable. As evident, good theory forms a basis for social and health work since it helps the professionals to explain the emergence of certain actions and behaviour and how they can act with regards to that (Reckwitz, 2002).


Even though the present SCR highlights several issues, which can easily be used to shift the blame from one party to the other, the most important aspect however is that it provided a clear analysis of what took place thus enabling individuals to learn important lessons that can enhance their practice; therefore serves its intended purpose. Herein, several factors contributed to the death of Daniel. To begin with, lack of information by the social service worker during the initial assessment. As mentioned, this could have prompted child protection services. It is difficult however to throw the blame to the local authorities since they were overloaded with work. In addition, the non-digitalized systems made the task more burdensome. The second factor relates to collaboration. Even though most agencies attributed their failure to aspects such as heavy workloads and being understaffed, the lack of follow up by social service agents and the lack of response from others made it difficult to follow the process thoroughly. This can also be attributed to poor leadership since as mentioned, Ofsted had lost its elements of specialism hence monitoring such cases was difficult. Another important aspect was communication, which affected the way individuals perceived the information, which also highlights the concept of optimism in social work. The use of theory in practice also played an important role. Had the social workers applied theory, then they would have been able to detect the child’s condition. Daniel was not only failed by his mother, but also with the systems put in place to protect his welfare. Even though in most cases, bureaucracy preceded over common sense, as social and health workers it is the duty of one to go beyond what is required to protect the welfare of the individual involved. Had this been done, Daniel’s young life could have been saved from the cruel encounters which led to his death. This work justifies the statement that no assessment of risk within a family or to a particular child can be effective without the direct engagement of the child, which can be achieved through observations and communication to gain experience of their wishes, feelings and experiences. One of the most valuable lessons learnt is that social work practices should be in line with theoretical concepts. In addition, social workers should be able to think outside the box, use common sense and place children at the centre of their work. And lastly, since the assessment process form the basis for social work, it should be treated with utmost importance. Information regarding incidences should be critically assessed to determine the presence of significant harm.



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