Last updated: 03.12.19

Serious Case Review: Daniel Pelka (2013)

Local authority: Coventry

What happened?

Four-year-old Daniel Pelka was murdered by his mother, Magdelena Luczak, and her partner, in March 2012, following a period of sustained abuse. On the day of his murder, the postmortem showed the cause of death was a serious head injury. Daniel’s father, Mr Pelka brought the family (Daniel’s mother and her daughter, Anna) to the UK from Poland at the end of 2005. Mr Pelka remained with the family until the end of 2008, after which time Luczak had two new partners. Her third partner, Mariusz Krezolek, contributed to Daniel’s abuse resulting in their criminal conviction in July 2013.

Daniel was invisible to professionals, although he came into contact with doctors and arrived at school with visible injuries. He was also observed scavenging for food from bins, and staff at the school he attended described him as a bag of bones. 

In January 2011, Daniel’s mother took him to hospital with a fractured arm, claiming his injury was sustained following a fall from the settee. Although the hospital raised immediate concerns and a meeting was held to decide if the injury was abuse, no discussions focusing on the reasons for bruising on the other parts Daniel’s body took place. In fact, the reasons Daniel’s mother provided for her son’s injuries were accepted.


  • Numerous police visits: Police were called to 26 separate incidents at the family home, many involving domestic violence and alcohol abuse.
  • Lack of professional curiosity: Daniel’s mother made excuses for her son’s injuries, which professionals accepted, demonstrating a lack of professional curiosity.
  • Complications of language: Daniel did not communicate much, because English was not his native language, he lacked confidence to talk.
  • Lack of evidence: No evidence of conversations held with Daniel about his home life, which could have revealed the abuse that was happening.
  • No action taken at necessary times: Daniel attended accident and emergency with injuries twice, though no action was taken.
  • Low number of health visitors in the Coventry area: This caused professionals to have high caseloads and insufficient time to exercise professional curiosity properly.
  • Cancelled appointments: The school nurse referred Daniel to the community pediatrician following her concerns around Daniel’s weight and behaviour. Although appointments were made, Daniel’s mother cancelled three appointments and missed others.
  • Lack of accurate record keeping: Between December 2011 and February 2012 the school noticed Daniel had facial injuries, though there was a lack of accurate recording keeping making it difficult for appropriate monitoring to commence.
  • High caseloads and inexperienced social workers: Social workers were managing high caseloads and newly qualified, inexperienced social workers were picking up complex cases.

Impacts on practice

  • Increased supervisions for social workers to check that their caseload is manageable.
  • Focus on supplying more training to frontline staff to help empower them to identify and report suspected abuse promptly, as well as keep appropriate records.
  • Assessed Year in Practice for social workers to provide further support and guidance to newly qualified social workers.

Read the full report here.