The Children’s Minister, Edward Timpson, is very right to challenge
the report of the Daniel Pelka Serious Case Review, as reported in Children and Young People Now.
The report does NOT answer many why questions, if any. Why did the professionals remain attached to
the view that Daniel’s problems stemmed from organic causes in the light of
evidence to the contrary? What factors impeded the sharing of information and the
keeping and use of accurate records? Why did assessments fail to reveal the problems in the family? Why
was the serious issue of domestic violence (between the adults) not given more
weight in assessments?
Timpson is right to complain that the report stops short of explaining
how problems in management, systems and processes, which are briefly referred
to, impacted on the case. Also the report mentions issues of training and workload
that are not explored. These all sound like ‘latent factors’ to me: weaknesses
that lurk beneath the surface of the organisation and which predispose to
error. Knowing more about them is key to building a safer organisation.
