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Online complaint form

When providing details of your complaint it is helpful if you can include specific information if you know it, such as names of staff involved and where the incident happened.

If you are complaining on behalf of someone else, we will need their permission for you to act on their behalf. If the patient is a child or lacks capacity to provide consent we will need proof of ID from you. We will ask for this information when we acknowledge receipt of your complaint.


Patient details:

Title:*

First name:*

Last name:*

Postal address including postcode:*

Contact number:

Email address:

Date of birth:

NHS number (if known):


Your details (if you are not the patient):

Title:

First name:

Last name:

Postal address including postcode:

Contact number:

Email address:

What relationship are you to the patient?

Spouse

Partner

Parent

Guardian

Other


Which site did the issue take place:*

Which ward did the issue take place:

Date the issue took place:*

Please summarise the issue that has led to you to make your complaint:*

Any additional information:


What would you like to happen as a result of your complaint? Please note that if we do not think that we can achieve what you want, we will let you know.

Apology

Explanation/information

Change in procedure

Prevent others having a similar experience

Other (please specify below)

Other:


The information I have provided is accurate to the best of my knowledge.*

Email 2*:

* required fields

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