Complaints form

Most problems can be sorted out quickly and easily, often at the time they arise with the person concerned
and this may be the approach you try first.

Where you are not able to resolve your complaint in this way and wish to make a formal complaint you should do so, preferably in writing as soon as possible after the event and ideally within a few days, as this
helps us to establish what happened more easily. In any event, this should be:

• Within 12 months of the incident,
• Or within 12 months of you discovering that you giving as much detail as you can.

If you are a registered patient you can complain about your own care. You are unable to complain about someone else’s treatment without their written authority.

You are also able to download our form (link below) to complete by hand.

Download Form

Title

First Name

Last Name

Address

Contact Number

NHS Number (if known)

Date of Birth

Which department/Service is your complaint about

Where did the incident(s) or event(s) happen that led to your complaint? Please be as specific as possible.

When did the incident(s) happen that led to your complaint If more than one date, please specify when the incidents/events occurred. Please give date and time or indicate the time period when they occurred, from and to.

Please describe the circumstances that have led you to complain.

Please include details of: Who was involved? You should confirm whether there are any witnesses and provide their names and contact details if possible. What was said and done? How has it affected you or the patient? What you think the practice failed to do, or did wrongly?

What do you think the practice should do to put things right, please say what outcome you would like to see from this complaint

This could be an apology, explanation, further appointment, a request for the practice to consider changing its processes or, other (please specify)

If there has been a delay in telling us of your complaint, please state why.

If no delay, please enter N/A

How would you like us to contact or reply to you?

Having completed our investigation into your complaint we will respond to the concerns that you have raised. How would you prefer us to contact you?

Letter

Telephone Call

Meeting

I give my consent for you to pass the information contained on this form to the appropriate service/organisations for consideration. I also understand that the appropriate service/organisations may share relevant information in order to complete the investigation into my complaint. I understand that this may include the disclosure of confidential personal information. If you are not the patient making the complaint, you must obtain the patient’s consent to act as his or her representative – please ensure that you tick the box below identifying that you are the complainant.

I consent

Important:

Complaints form