Daniel Pelka was starved, tortured and beaten to death by his mother and stepfather. Photograph: West Midlands police/PA
Pressure is growing for a national debate on mandatory reporting of child abuse after a damning report exposed how teachers, health professionals, social workers and police officers failed Daniel Pelka, the four-year-old tortured, starved and beaten to death by his mother and stepfather.
A serious case review published on Tuesday said the boy appeared to be invisible to the many professionals who had contact with him but did not step in. The review team could find no record of any conversation with Daniel about his home life, his feelings or his relationships with his mother and her male partners.
The report found that a vast number of professionals had contact with Daniel and his family but nobody put together the full picture of the abuse the boy was suffering at home in Coventry, where he was kept locked in a filthy box-room, denied food and subjected to physical torture.
All the agencies involved have accepted they should have done better and have explained measures they are taking to try to stop another youngster slipping through the net.
David Simmonds, chair of the Local Government Association's children and young people board, backed the call for a debate. "Today's report lays down a challenge to social services, the police, schools, health professionals and the wider community to review, and where necessary improve, the way we identify and deal with the heinous crimes of neglect and abuse," he said.
Mandatory reporting might be one element of driving change, Simmonds said, but he added: "We have to be sure that any reform does not have unintended consequences, such as overloading the system with cases where the child is clearly not in danger of abuse or neglect. We must avoid creating a situation where the social care system is swamped with unnecessary referrals because professionals lack the courage or confidence to take responsibility, exercise their judgment and act appropriately."
Paula Barrow, a mother of two from Manchester who is heading a petition for mandatory reporting and has collected 53,000 signatures in support, said: "Child abuse is a crime, yet reporting it in the UK is discretionary. We urgently need new legislation which requires the mandatory reporting of child abuse in regulated activities, to help better protect vulnerable children like Daniel Pelka."
Peter Garsden, president of the Association of Child Abuse Lawyers and adviser to the campaign group Innocence in Danger, said: "The introduction of legislation would remove many of the confusing and often conflicting considerations that staff presently have to make before they say anything to anyone about concerns they may hold."
Innocence in Danger is a member of the Mandate Now Coalition. Fay Maxted, the chief executive of another of the coalition members, The Survivors Trust, said: "Spotting the signs of child abuse can be challenging, and all too often reports that should be made are not because of misplaced loyalty to the institution or friendship with the alleged perpetrator. If law is introduced, staff will have no doubt what to do, and they would have legal protection from recrimination which presently can follow when a member of staff takes the conscientious step of reporting." The coalition says mandatory reporting works well in many countries, including the US.
Daniel's mother, Magdelena Luczak, 27, and her partner, Mariusz Krezolek, 34, both Polish nationals, will serve at least 30 years in prison for Daniel's murder. During a harrowing trial the jury heard that Daniel looked like a concentration camp victim when he died in March 2012. The court was told that he was subjected to torture, including having his head held under water until he passed out and being force-fed salt. He was systematically denied food before dying after receiving a blow to his head.
The report said Daniel's "traumatic abusive experiences" during the last six months of his life were shocking. "He must have felt utterly alone and worthless for much of that time, being the subject of his mother and stepfather's anger and rejection. At times he was treated as inhuman, and the level of helplessness he must have felt in such a terrifying environment would have been overwhelming. The extent of his abuse, however, went undiscovered and unknown to professionals at the time."
The review team accused Daniel's school of having a dysfunctional approach to children's safeguarding issues, highlighting that teachers had noticed injuries to his face and had locked away pupils' lunch boxes to stop him stealing food, but had not taken effective action to help him.
Health professionals and social workers had been too quick to accept that injuries needing hospital treatment, including a broken arm and a cut over the eye, were the result of accidents – though it also said they were under pressure because of high workloads and understaffing. The report criticised a community paediatrician who saw Daniel a month before he was murdered for putting his weight loss down to worms rather than possible abuse.
Apologising for its failings, Coventry city council's chief executive, Martin Reeves, said: "All organisations in Coventry involved in Daniel's short life now have to face up to their responsibilities and the part they played in the missed opportunities that could have protected Daniel. We are sorry we did not do enough to protect Daniel.
"The report makes clear that the sharing of information and communications between all agencies was not robust enough and no one fitted together the jigsaw of what was really happening to Daniel."
Reeves said the council had already improved working practices and training for its social workers and staff in schools.
Dr Sharon Binyon, medical director at the Coventry and Warwickshire Partnership NHS Trust, said training had been reviewed and new systems were in place.
The children and families minister Edward Timpson has written to the safeguarding board asking for further analysis of why the failures happened.
"The fact that, according to the report, there is no record of any conversation held with him by any professional about his home life, his experiences outside of school, his wishes and feelings, and of his relationships with his mother and her male partners speaks volumes," Timpson said.