Online form for complaints or concerns

Please complete the form below.

If you are raising a concern or complaint on behalf of someone else, please be aware that we cannot discuss clinical or personal information with you without the consent of the patient, if they are over 18 years old. We will be happy to contact them directly in order to request their consent; please ensure that they are aware that you have raised issues with us and provide us with their contact details.

How would you like us to deal with the issues you are raising? Required

As a concern

As a complaint

Is your concern or complaint about your own or someone else’s care? Required

About my care

About someone else's care

Your full name Required

Your date of birth Required

Europe/London

Your full address (including postcode) Required

Your telephone number Required

Your email address Required

Your preferred method of contact (e.g. letter, email, telephone) Required

Do you need any communication support? If so, please specify

If you are raising a concern or complaint about the care of someone else, please provide their details. Full name:

Their date of birth and/or hospital number

Their full address

Their email address

What is your relationship to the patient e.g. parent, child, sibling, carer, friend?

Would you like us to respond to you or to the patient?

Which hospital does your concern/complaint relate to? Required

Is your concern or complaint about inpatient or outpatient care? Required

Inpatient care

Outpatient care

Which ward or department is your concern/complaint about? Required

Date/s of the admission or appointment relevant to your concern/complaint Required

Does your concern/complaint involve a member of staff? If so, please provide their name, if known

Please provide details of what happened Required

Please tell us what expectations you have/outcomes you would like as a result of raising this concern/complaint e.g. staff learning, an apology, improvements to our service etc

Please provide any other information that you think might be useful to us in investigating and responding to this concern or complaint

I agree to the privacy policy.

If you would prefer not to use the online form, you can raise concerns and complaints by writing to or emailing us.

Alternatively, if you would prefer to speak with a member of the PALS and complaints team, please contact us on 01256 486766.

For further information about raising concerns and complaints, please view our leaflet here.

Online form for complaints or concerns

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