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:

Your address:

Section B - patient details:

Date of birth:

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.

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

Section D - issue(s) being raised:


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: 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):