Agencies missed crucial chances to intervene before toddler was killed by mum

AGENCIES missed crucial chances to intervene before a a toddler was murdered by her mum, an inquest has heard.

Katie Crowder was jailed for killing 19-month-old Gracie Crowder by scalding her in March last year.



Nottingham Coroner's Court heard she told a therapist she had thoughts of wanting to kill someone months earlier.

Assistant coroner Gordon Clow said this information was not shared with other agencies and may have helped Gracie.

Little Gracie Crowder suffered a cardiac arrest when she came into contact with the water at her home when she was 20 months old.

Her mum, Katie Crowder, 25, was arrested and charged with neglect and also faces a new charge of causing the death of a child.

Emergency services were called to the property where they tried to resuscitate the little girl but she was pronounced dead when taken to hospital.

Mr Clow recorded a verdict of unlawful killing and 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."

During his conclusion Mr Clow said Crowder, of Wharmby Avenue in Mansfield, Nottinghamshire was snorting up to three grams of cocaine daily and kept her relapse into drug use from family and support workers.

He also said she told a drug worker about feeling angry, paranoid and psychotic, and despite telling a therapist she had daily thoughts of wanting to stab someone, and that she went out at night armed with a knife – which was not passed on to safeguarding teams.

The coroner said Crowder would play down these graphic thoughts or give "watered down versions" to her support worker but still further assessments on her mental health and Gracie's safety were not carried out.

"It's not possible to determine whether or not mental health support would have made any difference," he said.

"This does not mean that if Katie Crowder had received help Gracie would not have died. Katie might still have made the same decisions on 6 March 2020."

Gracie suffered extensive burns to 65% of her body after hot water was poured over her and a post-mortem report concluded her death was scalding, the inquest was told.

Katie Crowder, who was 26 at the time, was jailed for 21 years at Nottingham Crown Court in December 2020.

Mr Clow said Crowder had kept information from agencies for fear of losing her daughter and had said she would not hurt Gracie.

'Paranoid and psychotic'

He said in his findings that Gracie's death had been the subject of internal reviews at all the agencies involved.

He said Insight Healthcare had "taken a good approach to learning from this tragedy" while Nottinghamshire Healthcare Trust could do more in improving record keeping and risk assessments.

Mr Clow said Nottinghamshire County Council could make improvements to its information gathering and in the way referrals from other agencies are dealt with.

Rosa Waddingham, chair of the strategic leadership group for the Nottinghamshire Children's Safeguarding Partnership, said: "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 has cooperated fully with the inquest and will now reflect carefully on what the 

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