Agencies missed crucial opportunities to save 19-month-old baby scalded to death with boiling water by her cocaine-using mother, 26, 審問は聞く
Agencies missed opportunities to intervene before a toddler was murdered by her cocaine-using mother, 死因審問は聞いた.
Katie Crowder was jailed for life after she was found guilty of murdering 19-month-old Gracie Crowder by scalding her with boiling water at home in Mansfield, Nottinghamshire in March last year.
Prosecutors said it was ‘not an instant death’, adding that ‘it would have taken in the region of one hour for her to die’.
At the inquest into Gracie’s death, assistant coroner Gordon Clow said that Crowder was snorting up to three grams of cocaine daily and kept her relapse into drug use from family and support workers.
He said Crowder told a drug worker about feeling angry, paranoid and psychotic, and told a therapist she had daily thoughts of wanting to stab someone, and that she went out at night armed with a knife.
しかしながら, this was not passed on to social care or safeguarding teams and this information could have saved Gracie, 審問は聞いた.
Katie Crowder was jailed for life for killing 19-month-old Gracie Crowder by pouring boiling water over her at home in Mansfield, Nottinghamshire in March last year
Gracie suffered a cardiac arrest when she came into contact with the hot water and died
At the inquest into Gracie’s death, assistant coroner Gordon Clow said that Crowder was snorting up to three grams of cocaine daily and kept her relapse into drug use from family and support workers
Gracie suffered a cardiac arrest when she came into contact with the hot water and died. Her mother Crowder was jailed for life in December last year.
Recording a verdict of unlawful killing, the assistant coroner said: ‘Gracie’s death was part of a deliberate act by her mother.’
He said agencies were not responsible for the death but added: ‘Opportunities to intervene were missed and risk assessments were not done because of poor information sharing and record keeping.’
Crowder told a drug worker about feeling angry, paranoid and psychotic, and told a therapist she had daily thoughts of wanting to stab someone, and that she went out at night armed with a knife
Mr Clow also spoke of the role of Insight Health Care in Nottingham after Crowder contacted the service on the recommendation of her GP.
‘She described she was having daily thoughts of stabbing people,’ 彼は言った.
‘She disclosed thoughts and actions in relation to violence and ”I am now off cocaine and going to groups but I’m now getting psychotic. I don’t want to hurt anyone but getting really angry and paranoid”.
‘The comments were made to a therapist by Crowder who noted, ”patient said she was ‘going out armed with a knife”’。’
The inquest heard that the call was made on August 5, 2019, and the therapist followed the process of phoning the crisis team and local heathcare trust.
The therapist had passed on the details, but the healthcare trust gave evidence that the call was a request ‘for advice only’.
The therapist had not passed the matter on to children’s social care and ‘an opportunity to intervene was missed’, Mr Clow added.
And he told the hearing that Gracie’s death was a result of a deliberate act and none of the agencies were responsible for her death.
Gracie’s medical cause of death was ‘scalds’ after she suffered a large area of life-threatening burn injury, 審問は聞いた.
Crowder was found guilty of murdering Gracie and was jailed for life in December last year
Crowder was 26 when she was jailed for life at Nottingham Crown Court.
The coroner said three agencies were involved with Crowder at the time and sought to access urgent help and support for her.
He referred to Notts Healthcare Trust regarding record-keeping, thresholds, risk assessments in unusual circumstances and the coroner said ‘in my view more can be done in those areas’.
He also said concerns had rightly been identified regarding information gathering after evidence was heard from Nottinghamshire County Council’s social care department.
Rosa Waddingham, chair of the strategic leadership group for Nottinghamshire Children’s Safeguarding Partnership, 前記: ‘The death of Gracie in such circumstances is absolutely tragic and our heartfelt condolences are with everyone who loved and cared for her.
‘The partnership will now reflect carefully on what the coroner had to say in considering whether any further action is needed.’