NHS Nottingham and Nottinghamshire Clinical Commissioning Group

Health and care · Clinical commissioning group

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First report 23 Jun 2021•Latest report 23 Jun 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS Nottingham and Nottinghamshire Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Hazel Ann Binks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hazel Binks died on 14 January 2021 after placing a fastened plastic bag over her head, following earlier preparations to asphyxiate herself and leaving a farewell note. The principal concerns were that information about her suicidal thoughts was not passed from the GP practice administration to the GP, that the GP did not undertake a meaningful mental health or risk assessment, and that the practice’s internal review did not identify these issues.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Nottingham and Nottinghamshire Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake meaningful mental health or risk assessments

    Wider context from the report

    “(2) Dr ████████ did not undertake any meaningful mental health or risk assessment during the consultation with Hazel. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Nottingham and Nottinghamshire Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately take and pass on important patient information

    Wider context from the report

    “(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. The 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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Nottingham and Nottinghamshire Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficiently robust internal reviews failing to identify and address important patient safety issues

    Wider context from the report

    “(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 Dr ████████ mental health or risk assessment of Hazel. I am concerned that the GP practice may not be undertaking sufficiently robust internal reviews, and consequently is not recognising and addressing important issues in patient provision of safety and is not taking necessary corrective action, that the CCG will wish to consider these concerns given the CCG’s relationship with GP practices within its area. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026