The review by independent consultant Jane Wonnacott found that stress brought on by high volumes of work resulted in frontline practitioners making poor professional decisions and their managers not supervising them effectively.
The review is a long-awaited follow-up to the initial serious case review (SCR) published in September 2013, which was criticised by children’s minister Edward Timpson for failing to answer key questions about what went wrong in the run up to Daniel's death.
Titled A Deeper Analysis of the Findings into the Serious Case Review of Daniel Pelka, the report found Coventry’s children’s social care referral and assessment teams were under pressure as a result of staffing problems elsewhere in the department in the period leading up to Daniel’s death in March 2012.
It discovered that management action to improve the consistency of assessments in a system that was under pressure was misinterpreted by teams as condoning the production of assessments that were of poor quality and lacking detail.
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