PALS online form

Please be factual in your feedback. It is helpful if you provide us with specific information if you know it, such as names of staff involved and where the incident happened.

If you are contacting us on behalf of someone else, we will need their permission for you to act on their behalf. We can do this over the telephone or by speaking to them in person.

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?

Please provide a phone number for us to contact the patient involved

Please be aware that it is a legal requirement for us to have written or verbal consent of the involved patient before we can investigate and share any issues that you wish to raise with our Trust.

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 you to contact PALS:*

Any additional information:

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

Other:

How would you like the investigating officer to contact you?

Other:

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

* required fields