Complaint Form

Thank you for taking the time to complete this form.

Please complete the boxes below with the required details.

If you are the patient, please complete the patient details in Section B only.

If you are raising a concern on behalf of a patient, please complete Sections A and B.

If you raising concerns on behalf of a patient, we will need authority by completing Section C. If the patient is unable to give consent, or has passed away, please let us know so that we can seek authority from the person who has Power of Attorney for health and welfare or the Executor of the Will.

Section A - complainant details:

First name:

Surname:

Your title:

Your address:

Address 1

Address 2

City

Country

County

Postal Code

Preferred contact telephone number:

Email address:

Section B - patient details:

First name:

Surname:

Date of birth:

Europe/London

Gender:

Address:

Address 1

Address 2

City

Country

County

Postal Code

Preferred contact telephone number:

Email address:

Additional contact information:

Preferred contact method:

Section C - patient authority:

To respond to the issue raised we will need to seek authority from the patient. Please select your preferred method for us to gain authority.

Who to contact for authority:

Please send authority form by:

If verbal is selected, we will contact the patient for authority on the telephone number provided.

If the patient is unable to give consent, or has passed away, please choose one of the options below:

I am / require authority from the Executor of the Will for the patient who has passed away. Please send me an authority form.

I understand that a copy of the relevant documentation identifying the Executor of the Will needs to be provided along with the completed authority form.

I am / require authority from the individual who holds Power of Attorney for Health and Welfare as the patient is unable to give authority. Please send me an authority form.

I understand that a copy of the relevant documentation identifying the individual who holds Power of Attorney will need to be provided along with the completed authority form.

Section D - issue(s) being raised:

Please detail the issue(s) experienced by the patient: Required

Please provide specific questions or areas of concern that you want us to address:

To assist us in addressing your concerns effectively, please let us know how we can make things right for you:

I agree to the privacy policy

Thank you for completing the complaint form.

After we receive your form and relevant authority, a member of our Patient Experience Team will contact you you. They will discuss how you would like the issues raised to be handled and agree on a timeframe for our response.

If you require support in completing this form, please contact our Patient Experience team on 01983 534850 or email: iownt.complaints@nhs.net. You can also visit our Patient Advice and Liaison Service in person at St Mary's Hospital.

For support to raise a complaint via someone who is independent of the NHS, please contact the South West Advocacy Network (SWAN):