Quality Care - everyone, everytime
 

Isle of Wight NHS Trust Complaints Form

Please complete the boxes below with the required details.  If you are the patient please complete the patient details.  If you are raising a concern on behalf of a patient please fill in the complainant and patient details.

Please note:  If you raising concerns on behalf of a patient we will need authority by completing section B.  If the patient is unable to give consent or has passed away please let us know as we will need to seek authority from the person who has Power of Attorney for Health and Welfare or the Executor of the Will.

If you wish for us to contact you via telephone, please leave your phone number in the field provided later in this form.

Section A: Details 

Complainant Details:

Gender
  


Patient Details:

Gender:
  
Preferred Contact Method *
   


Section B: Patient Authority

In order to respond to the issues raised we will need to seek authority from the patient.  Please tick the method of authority which is best:

Who to contact for authority:
 
 
Please send authority form by:
   

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

 
 

However, I would like the opportunity to discuss priority with a member of the SEE Team in more detail.

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

Authority Required:
  

Section C: Issues being raised

 

Once completed please click the submit button below.

When your form and relevant authority has been received, a senior member of staff will be asked to contact you in order to negotiate how you want the issues raised to be managed and to negotiate a timescale for responding.

If you require any support in completing this form please contact the SEE team on 01983 534850 or access the PALS team in the main reception area of the hospital or email quality@iow.nhs.uk

Alternatively, if you would like support to raise a complaint via someone who is independent of the NHS please contact the Health Complaints Advocacy Service using the details below:

Tel: 0330 440 9000

Fax: 01424 204687

Email: info@seap.org.uk

Web: www.seap.org.uk

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