By Lisa Dowd, Midlands Correspondent
A serious case review will look at whether authorities missed numerous opportunities to intervene and stop the horrific abuse being meted out to Daniel Pelka by his mother and her partner.
During the trial of Magdelena Luczak and Mariusz Krezolek, Birmingham Crown Court heard that the four-year-old, who was starved for up to nine months before being beaten to death, had been assessed by doctors for a broken arm as early as January 2011, some 14 months before he died.
Krezolek claimed that Daniel had fallen from a sofa during a game of hide and seek but Dr Irena van der Ploeg was concerned that between 12 and 24 hours had lapsed after his injury, before he was brought to University Hospital Coventry.
Doctors said Daniel would have been in "significant pain" having suffered a "spiral fracture" which could have been as a result of "twisting". Daniel's two bone fragments had become "completely separated" and they suspected it was a "non-accidental injury".
A police officer who was in charge of child protection was called by a social worker at the hospital.
A sibling of Daniel's, who had been told to lie about what had happened by Luczak and Krezolek, was spoken to by authorities, but it was decided there was no evidence of wrong-doing.
In a statement read to court, DC Holly Darby from West Midlands Police said: "A strategy meeting was held at University Hospital Coventry and it was decided there was no role for child safety officers at this stage."
At school Daniel would steal food from the bin, the prosecution said Five months later, social services closed their file on Daniel.
During the trial, Prosecutor Jonas Hankin QC alleged the fractured limb may have been a trigger for the later abuse, which escalated after Daniel began attending school in September 2011.
Up to his death in March 2012, the court heard that Daniel missed 28-and-a-half days of school. Between October and mid-December 2011, the school nurse, a school health support worker and an educational welfare officer all made visits to Daniel's home, after Luczak described her son as being "obsessed with food" and having an "insatiable appetite".
By January 25, 2012, a teacher had "grave concerns about Daniel" and contacted his GP. The following day she spoke to Luczak and advised her that she needed to make an appointment for her son.
Neither the GP Daniel was registered with, or any other doctor at the practice ever saw Daniel, despite various letters being sent to his mother telling her he needed his injections.
And, although the school nurse referred Daniel to the community paediatrician two months prior to this, the family missed three appointments before Dr Supratrik Chakraborthy eventually saw the child on February 10th 2012, a few weeks before Daniel died.
Daniel was so thin that a teacher could see his ribs The trial heard Luczak played a leading role in convincing school staff and medical professionals that Daniel's dramatic weight loss was due to a rare eating disorder.
She and Krezolek told Dr Chakraborthy, an expert in child protection, that they had seen worms in Daniel's stools. The doctor noted that Daniel looked "thin" but not "wasted", and he prescribed medication for worms.
By then, teachers at Daniel's school, Little Health Primary in Coventry, had observed Daniel "stealing" food from the lunch boxes of other pupils, and taking food from bins.
The same month a teacher described telling Daniel to get undressed for PE, but said that he "sat and whimpered". When his clothes were eventually taken off, she "could see his bones", his skin looked "transparent" and she thought he was "wasting away". Teachers felt he had the "bare minimum" of food in his lunchbox but believed it to be "adequate".
At first Daniel had been told off and punished by staff for taking food, but by now they thought he "couldn't help it", it was happening every day, and they believed it to be "health- related".
On March 1, 2012, just hours before Daniel received the fatal blow that led to his death, teachers saw him eating half eaten fruit out of a bin and eating green play jelly. They described his skin as "ashen", he was "quiet" and "more withdrawn", was "cold to touch", his lips had a "blue tinge" and he had dark circles around his eyes. His clothes were "too big" for him.
Peter Wanless, chief executive of the NSPCC, said the Serious Case Review must give an indication of how Daniel's mistreatment was missed.
Daniel's mother convinced teachers and doctors he had an eating disorder He said: "The distressing evidence given by Daniel's devoted sibling, who bravely risked their own safety in a bid to protect him, shows just how lonely and desperate the situation had become.
"But protecting Daniel from abuse should never have been the responsibility of a child. It is clear that there were adults in Daniel's life who had concerns for his welfare.
"Magdalena Luczak and Mariusz Krezolek deliberately span a web of lies to cover up their evil abuse and evaded any help they were offered. However, once again crucial questions need to be asked about how a youngster slipped through the child protection net with the most catastrophic of consequences.
"The indications that Daniel was suffering for some months should have been plain to see - he was disappearing in front of people's eyes."
Anyone who is concerned about a child can contact the NSPCC helpline immediately on 0808 800 5000, text 88858 or email help@nspcc.org.uk.
The serious case review by Coventry's Safeguarding Children Board is expected to report its findings within six weeks and will examine why social services and police did not become involved again after school staff noticed "finger pressure marks" on Daniel's neck in January 2012 and what appeared to be two black eyes in February 2012.
The review board have released this statement: "The review to date has scrutinised and challenged the actions of all the agencies and organisations that had an involvement in Daniel's life.
"It has considered whether more could or should have been done to protect Daniel. However new information has emerged during the trial. Therefore the Safeguarding Children Board will consider the work completed so far on the review in the light of all the evidence presented in court."
This latest review comes three years after the findings of a Serious Case Review in Birmingham which looked into the death of Khyra Ishaq, 7, who was starved to death by her mother and her boyfriend.
It concluded that her death was "preventable" and recommended there be "better assessments" and "effective inter-agency communication".
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