Serious Case Review: Impact of personal, professional and social issues on collaborative working


Serious Case Review: Impact of personal, professional and social issues on collaborative working



The publication of SCR (serious case reviews) is almost always met with anxiety and professional questioning regarding practice flaws, in addition to triggering understandable apprehension regarding how the media and public will react (Hudson 2013). Collaborative practice entails an ongoing cooperation between two or more disciplines or professional (Pollard, Thomas & Miers, 2009), with the goal of exploring and solving common issues while also granting the patient a platform to participate. Such inter-professional collaborative practice has been found to promote decision-making and communication, thereby facilitating synergy in grouped skills and knowledge (Levi 2014). Key components of collaborative practice include coordination, responsibility, cooperation, accountability, mutual trust, communication, autonomy, and respect (Pollard, Sellman & Thomas 2014). These aspects are vital in determining team effectiveness through open communication, equality of resources, and autonomy (Koubel & Bungay 2012). One area where collaborative practice is necessary is when undertaking serious case reviews (SCRs) due to their complex nature. According to Brandon et al. (2013) two out of three SCRs involves children below the age of five. IN other words, majority of these children are under the care of their families/carers, and this further adds to the transparency and complexity of information sharing (Ofsted 2011). According to the NSPCC (2016), a SCR occurs following the death of a child, or it has been established that a child has been seriously abused, neglected, or injured. Accordingly, a SCR is usually conducted with a view to examining lessons from such an incident that will in turn prevent a reoccurrence in future (Office for Standards in Education, Children's Services and Skills 2009). SCRs are thus an ideal learning platform for organisations to protect children better. According to Brandon et al. (2012), reviews aimed at acknowledging learning could enable organisations to not only change, but also act as an ideal environment that facilitate the safe improvement and challenge of both practice and system. The premise of this essay is to succinct explore the positive aspects of team working involved in the case of Daniel Pelka, who was murder at 4 years and 8 months in 2012. In addition, the essay examines areas of this particular SCR that demands further development in order to ensure successful collaborative practice.

Impact of personal, professional and social issues on collaborative working and the service user and carer experience

Integrated and Collaborative working in SCRs

The recent publications of SCRs such as that of Daniel Pelka and Baby P have emphasized the dangers that could befall child protection services in case the various professionals fail to work collaboratively (Rogers 2013). These cases further underscores the importance of collaborative practice and integrated working by emphasising on the need for the multi-agencies involved in these cases to share communicate effectively in terms of sharing relevant concerns and information about vulnerable children involved (Thistlethwaite 2012). Safeguarding children calls for the concerted effort of various professionals who have to work under a multi-agency environment in order to identify issues and concerns raised regarding a given SCR and hopefully, find a lasting solution to these problems. This requires that professionals interact at great length with families.

            A good relationship with families is crucial as it helps to capture key information regarding the incident (National Institute for Health and Clinical Excellence 2009). It is important however to note that because various agencies are involved, this adds to the complexity of the whole process and the contributions of each agency to the ultimate outcome. However, Multi-agency working is important in such situations in that is offers support to children and families in need of extra assistance in an efficient and effective manner, thereby preventing or reducing any challenges that could arise (Miller 2014). There are various benefits that could accrue from integrated working as the various professionals execute a holistic approach. Moreover, such collaboration among inter-professionals creates better quality services.

Besides, integrated practice enables the multi-disciplinary team to detect any difficulties or challenges early enough through efficient sharing of relevant concerns or information, thus ensuring timely intervention (Goodman & Clemow 2010). Furthermore, integrated working enable families and carers to develop closer relationship with the multidisciplinary professional throughout the entire process of assessment and/or intervention (Day 2013), thus leading to better engagement and support of families, and as a result, the needs of the child can be met.

The SCR of Daniel Pelka elicits vivid and distressing thoughts on the catastrophic consequences facing children, in the event that public agencies charged with protecting them fail, for whatever reason, to prevent the death of such children (Daniel et al.2011). Protecting children is undoubtedly one of the most demanding tasks of public services. In demands good utilisation of authority (Finkelhor 2008), inquiring minds, as well as great skill in perceiving the life of children, their families, and carers. The work tends to be quite complex and messy (Laming 2009), and often calls for timely and balanced professional judgements (Meadows et al. 2011). Accordingly, effective communication and sharing of information is essential in the provision of safe and high quality practices (Levi 2014). Issues in communication are a key aspect in causing patient harm.

Professional issues

The team working on Daniel Pelka's case has ineffective on certain fronts, especially in regards to inter-agency communication. For example, assessments of Daniel within the school failed to identify risks and failure to collate all the information available to them. Daniel had recurring head injuries but the school nurse did not take the matter up with social care (Lock 2013). The police also failed to fully identify or perceive the risk to which Daniel was faced with living in a volatile household. This, even as the police had been called to the family home on 26 separate incidents spanning over four years. Although Daniel was seen by a paediatrician in February 2012, it was not apparent that the weight loss could have been the result of child abuse (Lock 2013). At school, Daniel scavenged for food in bins but the school assistant did not try to establish the root cause of this. These incidents, amongst many more, point towards the fact had there been proper communication and sharing of information regarding Daniel by the various professionals involved, it would have been possible to find out the main cause of the problem.

Poor practice, leadership, as well as a fragmented child protection system also played a role. This implied that different professionals were responsible for child protection, attendance, and health (Devaney et al. 2013). Lack of proper leadership of the team involved in Daniel's case led to ineffective communication across the multidisciplinary team. At school, the staff team failed to effectively communicate concerns regarding Daniel, while the school also lacked a formal mechanism for the compilation of information.  When it comes to the children's social care, this was characterised by ineffective supervision because the team manger trusted the judgement of senior practitioners. An over-reliance on experienced supervisors and workers who lacked sufficient support and training resulted in ineffective management oversight.

            Whereas social workers conducted various assessments involving Daniel's family, they failed to connect a combination of alcohol misuse by Daniel's mother and her male partners, parental mental ill health and domestic violence as potential risk factors for the children, including Daniel (Lock 2013). This could have been the result of insufficient training by social workers. Again, there is no evidence that the police and social services shared information or their findings on the matter.


The referral processes involved in Daniel's case were deficient. Since the professionals did not share information and their concerns about Daniel, they each formed their own conclusions which were not also shared. If there had been efficient sharing of information and concerns, it would have been possible to also institute effective referral processes (Munro 2011). For example, after the school assistant noticed a recurring head injury on Daniel, she could have informed the school nurse to follow up the matter. On the matter of domestic violence referrals involving children, the police and social work managers regularly held joint screening meetings to discuss domestic violence incidents. The joint meeting made decisions on if there was need to make referrals to children's social care.

Limited administrative support meant that the entire process would take more time than was necessary. In the case of Daniel, there was a delay in entering the relevant information to social care records (Lock 2013). Consequently, when the social worker was sent to undertake an initial assessment, she lacks all the information that was required, such as Daniel's mother alleged violent behaviour. This made it hard to identify the full extent of the domestic violence to which Daniel was subjected to. This failure to capture important information affected the practice of other professionals. For example, when the health visitor came calling after the birth of Adam (Daniel's step-brother), she had no idea that there had been previous concerns about Daniel's broken arm, alcohol consumption, and domestic violence.

The health visitor could not record Daniel's eating problems and behaviour as described by his mother because Daniel's file could not be accessed (Lock 2013). When a midwife attending to Daniel's mother when she was pregnant with Adam called children's social care with domestic abuse concerns, the social worker could not associate such concerns with the records available to them regarding Daniel.  Consequently, it became hard for various professionals to establish the full extent of the difficulties and the seriousness of the problems facing the household, especially domestic abuse incidents.

When Daniel was referred to a GP with a broken arm, the GP in his records only identified lack of attendance to previous follow up appointments and the nature of the injury. There was no mention of any possibility that the injury could have been non accidental (Sidebotham et al. 2011). This is a clear sign that the GP did not have access to information that Daniel was being physically abused by his mother. It only emerged when Daniel was referred owing to his eating “problems”. 

Although the police had well kept records on basic information regarding Daniel, such files were rarely reviewed by senior managers. For instance, it emerged from the review report that the investigation by police into Daniel's broken arm was never reviewed by a manger. Accordingly, the investigation process could not be subjected to an external challenge.  There was also a high level of assumption amongst the professionals regarding emerging issues relating to Daniel (Lock 2013). For example, Daniel started demonstrating an obsession with food while at school. For example, he resorted to taking other children's lunchboxes and would proceed to eat in secret. The school administration did not try to establish the cause of Daniel's behaviour but increased, resorted to locking food away. This is because they had relied on information given by Daniel's mothers in explanation to his hunger namely, that his hunger was as a result of a pre-existing medical condition. The school confronted Daniel's mother once more when they grew increasingly concerned about his always being hungry and his other indicated that Daniel had a tendency to rise up very early and would consume plenty of food. The school never cared to verify this information and instead, took it at face value.

Personal Issues:

A few personal issues also emerge on this case. One of which is the communication style. As noted earlier, Daniel could not communicate effectively in English. However, the multi-agency team used English as its language of communication (Lock 2013). This presented the case with a key language barrier problem. This becomes evident when the school assistant asked him about the head injury and he just looked down and said nothing. Perhaps he was not sure how to respond. His lack of proficiency in English thus meant that his voice could not be heard. It could also have been a contributing factor to his apparent “lack of confidence”. More importantly, the multi-agency team treated Daniel as “invisible” in the sense that he was never consulted about anything, including his recurrent head injury or his scavenging behaviour at school (The British Association of Social Worker 2016). Another personal issue that emerges from this SCR is that the various professionals were too trusting of Daniel's mother, and hence failed to identify her conniving behaviour and high level of deception. For example she would lie to the police that she was not drunk even though it was quite obvious she was. Also, the social worker and the paediatrician believed her version of the story that Daniel had hit his head on the sofa accidentally.

 It is thus obvious from the case that the professionals failed to employ an 'enquiring mind' regarding Daniel's care. If they had, they may have been inclined to speak to him and even enlist the services of an interpreter. However, this was never done. The professionals also harboured the belief that the agreed processes and systems were adequate ensure child protection (Thompson 2016). However, these processes and systems were, to ay the least, consistently applied in Daniel's case. Moreover, various professionals assumed that another professional would assume responsibility over Daniel's plight.

Social Issues

Language barrier was also a leading social issue in Daniel Pelka's SCR. He had poor language skills in the sense that he could not speak English fluently (Lock 2013). For this reason, professional involved in the case isolated him with the result that the case lacked a child focus about it. It is also important to note that the various professionals who visited this home of various occasions failed to identify that Daniel was being abused by his mother and his male friends. At school, Daniel was not engaged with the other children probably because he was always hungry. The fact that he was not proficient in English did not help matters as it affected his self-confidence.   

Conclusions and Recommendations

The tragic case of Daniel underscores the importance of effective communication and follow-up when working in collaborative practice involving professionals from multiple agencies. In the case of Daniel, the police had good record of domestic violence and alcohol consumption which formed the basis of the problems faced by Daniel. Her mother was physically abusing him, had mental issues, was involved in a series of relationships, and frequently got drunk. Lack of sharing such crucial information between other professional such as social workers, health visitor, the GP, and school staff meant that no conclusive findings could be established. In addition, the professionals treated Daniel as “an invisible” despite the fact that they were investigating a case of which he was the primary victim.  Although it was established that he could not communicate in English, no attempt was made to enlist the services of a translator.  However, the publishing of this review has enabled us to see where issues in SCR arise. It has also made professions realise the importance of adapting a more holistic approach in handling multiple incidents of domestic abuse, especially where children are the victims. It is thus a wake up call for agencies to appreciate the importance of sharing information amongst themselves. It is also important that the Government and relevant professional bodies institute laws  and policies that will see to it that social workers, police, NHS staff and teachers involved in such incidents are disciplined or sacked for falling for to deception and misleading by Daniel's mother and her boyfriend. Consequently, Daniel continued to be physically abused, tortured and denied food, and he slipped through the cracks. While it is difficult to entirely eliminate human error from child protection work since staffs are usually overworked and hence stressed, effective supervision and management can help to minimise such decisive errors as the one involving Daniel. This calls for strong leaderships in the various organisations as regards risk management.





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