Concerns and complaints form

Please complete the fields below to tell us about your concern or complaint.

We will acknowledge your complaint in writing within three working days. The appropriate senior manager will investigate.

We aim to send you a response within 35 working days. If this is not possible, we will write to you to explain.

Reporting concerns and complaints on behalf of another patient

If your complaint concerns a relative, please include the full name, address, and date of birth of that person. Please note in this instance signed patient consent will be required or alternatively a copy of Lasting Power of Attorney.

I would like to report a:

Concern Complaint

Concern
Your concern will be managed by the PALS team, who will facilitate resolution of a current/ongoing concern regarding your care, or that of someone close to you, as quickly as possible.

Complaint
A complaint is an expression of dissatisfaction about any aspect of SASH services that can be made by a patient, carer, family member or service user. The Trust will carry out an investigation and a formal response is then provided in a method agreed with you. This can be in writing, by phone or a meeting.

Please note: We will need your contact details in order to be able to respond to you. Please fill in as many details as possible.

Reporter

Title

Miss Ms Mrs Mr

Your date of birth

Please use this format: dd-mm-yyyy

Please enter your full address, including post code

Are you filing a report about a patient other than yourself?

Yes No

Please note: Patient's consent is required whenever a complaint/concern relates to the treatment received by the patient and the person raising the complaint/concern is not the patient.

The consent needs to be obtained before confidential or information of a sensitive nature is released to a third party.

We will acknowledge your complaint/concern and send you a consent form to be signed by the patient involved.

Please fill in as many patient’s details as possible.

Patients details (if different from reporter)

Patient date of birth

Please use this format: dd-mm-yyyy

Please enter your patient's full address, including post code, if known

Report details

Please enter the date of the event or incident which has prompted you to report a concern or complaint.

Please use this format: dd-mm-yyyy

I have read and accept the terms & conditions.

I accept

Concerns and complaints form

Reporting concerns and complaints on behalf of another patient

Reporter

Patients details (if different from reporter)

Report details

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Telephone 01737 768 511

Concerns and complaints form

Reporting concerns and complaints on behalf of another patient

Reporter

Patients details (if different from reporter)

Report details

Follow Us

Get in touch

Change Text Size:

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