Complaints Submission Form
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Patient Details
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Patient's full name (As recorded on their medical records)
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Patient's date of birth
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Patient's NHS number or hospital number
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Patient contact details
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Complainant Details
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What is your relationship to the Patient?
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--- Select Option ---
I am the Patient
Spouse / Partner
Child
Parent
Carer
Other
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Please proceed to the "Your Complaint" Section
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Your full name and contact details
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Your full name and contact details
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Your full name and contact details
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Your full name and contact details
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Your full name and contact details
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Your Complaint Details
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Date of admission/event (if known)
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Which hospital/ward/team would you like to complain about (if known)
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Have you raised your concerns to the Ward or Service directly prior to making a complaint?
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--- Select Option ---
Yes
No
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Please provide details of who you spoke to, what was discussed and the outcome of the conversation.
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Have you raised your concerns with PALS prior to making a formal complaint?
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--- Select Option ---
Yes
No
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Please provide details of who you spoke to, what was discussed and the outcome of the conversation
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PALS is an informal service available to patients and their families and carers. They can help you get a quick answer to your concerns or signpost you to the most appropriate service. Would you like to raise your concerns with the PALS team instead of making a formal complaint?
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Yes
No
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Please return to our web page to find out more about how to contact PALS about a question, query or concern https://www.worcsacute.nhs.uk/contact-us/leave-your-feedback/pals/
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Details of your Complaint - Please give a summary of events, or details of your experience which has led to you raising a complaint. Please include dates, times, locations and names where known. This will help us conduct a more thorough investigation.
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Please share any specific questions you'd like answering as a result of your complaint
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Please provide details of your desired outcome as a result of your complaint
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Any other information you'd like our Complaints Team to know
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Submit
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