Hazel Binks
PFD Report
Historic (No Identified Response)
Ref: 2021-0220
No published response · Over 2 years old
Response Status
Responses
0 of 3
56-Day Deadline
19 Aug 2021
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
_ (1) The GP practice admin did not pass on the concerns of suicidal thoughts to the GP_ This was clearly very important information for the GP to have for the consultation. fact that this information was not passed on indicates a need for the practice to check that guidance and processes are in place for the accurate taking and passing-on of important patient information: (2) Dr did not undertake any meaningful mental health or risk assessment during the consultation with Hazel: (3) The GP: practice undertook an internal review of Dr consultation after Hazel's death (a Significant Event Analysis): This was attended by GP partners and the practice manager: The review did not identify that the GP practice admin did not pass on the concerns of suicidal thoughts to the GP. The review did not identify any insufficiency in DrB mental health or risk assessment of Hazel: am concerned thatthe GP practice may not be undertaking sufficiently robust internal reviews, and consequently is not recognising and addressing important issues in .patient provision and safety and is not taking necessary corrective action. likely her The that the CCG will wish to consider these concerns given the CCGs relationship with GP practices within its area:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Report Sections
Circumstances of the Death
Hazel Binks died at her son daughter-in-law's house on 14 January 2021 due to lack of oxygen caused by her placing a fastened plastic over her head. Hazel had become concerned that she was suffering from sexually transmitted disease due to various symptoms she had although up to her death there was no evidence that this was the case There is reason to consider that there was degree of irrationality to her belief, particularly as Hazel referenced an event many many years previously as being the cause_ On. 10 January Hazel had made preparations to asphyxiate herself with a plastic and wrote a farewell note. Her family became aware and it was arranged for her to stay with them to try and keep her safe On 11 January Hazel had_ a GP consultation to discuss her physical symptoms. Her; daughter-in law was with her and raised concerns that Hazel had suicidal thoughts: Hazel explained this as her 'getting into a state' and the GP did not ask any probing questions as to the details intent; or_her_current_thoughts: Hazel was_given_mental and bag bag health helpline and self-referral information, advice if there was an emergency, and was asked to book a two week follow up GP appointment On the evening before her death Hazel did not express any' suicidal thoughts and did not raise any immediate concerns for her family. On the evidence and on the balance of probabilities Hazel undertook a deliberate act with the intention of taking her own life given the nature of the act; the previous preparations on 10 January, the content of the two notes she left which read as farewell notes, and her state of mind_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.