Formal Complaint or Informal Concern Form | Blackpool Teaching Hospitals NHS Foundation Trust

This form will be used to enable a Patient & Family Relations Officer to assist you with your informal concern or to register your formal complaint for investigation.

INFORMAL CONCERN – One of the Patient Relations Officers will liaise with the Ward/Area on your behalf and discuss your concerns. The officer or a member of staff from the area will then contact you with a response. You can be contacted by email or telephone. Informal concerns are taken seriously and logged accordingly so that lessons can be learned.

FORMAL COMPLAINT – If, however, you wish to make a more formal complaint then the officer will register the case for investigation and either a letter of response will be sent to you from the Chief Executive’s Office or alternatively a meeting can be arranged to enable you to discuss your concerns face to face and a summary of the meeting is provided.

A member of the Patient & Family Relations Team will contact you either by telephone or email to discuss the concern/complaint.

Please select whether this is a formal complaint or informal concern:
Informal ConcernFormal Complaint

How would you prefer the formal complaint to proceed:
Letter responseAttend a meeting

Is this complaint or concern about yourself, or are you complaining on someone else's behalf?
about myselfon behalf of someone else

Please complete the following details about yourself:
Title

First name:

Surname:

House Number / Name:

Street Name:

Town/City:

County:

Postcode:

Telephone:

Email address:

How would you prefer to be contacted?

Is there anything we can do to make it easier for you to access our service? For example, you may wish to receive information from us in large print:

If you need independent help you can contact your local Advocacy Service for advice and assistance

Blackpool Postcode (FY1, 2, 3, 4) – Empowerment Advocacy Service
Tel: 01253 477959
Email: admin@empowermentcharity.org.uk

Other Lancashire Postcode area – N-compass
Tel: 0345 013 8208
Email: admin@n-compass.org.uk

Please note we will need your consent to discuss your case with your advocate.

What is your relationship to the person you are representing?

Why can't they raise the concern or make the complaint themselves?
The person is a childThe person is not well enough to do itThe person does not have the ability to do it themselvesThe person would prefer me to do it for themThe person has diedOther reason (please provide details)

NOTE:
If you are raising an informal concern or formal complaint on behalf of someone else, we will need their consent to discuss the case with you. If the person is unable to consent we will require a Power of Attorney document for Health and Welfare or evidence from their medical records to show we can discuss their care with you (the Patient & Family Relations Officer will discuss this with you and provide you with a consent form for the person to sign via email or post).

If the person has died we will require a Proof of Representation document such as a copy of a Will, Grant of Probate, Letter of Administration or evidence from their medical records which shows you as the person legally entitled to request information about the person’s medical care (the Patient & Family Relations Officer will discuss this with you).

Please complete the details of the person that you are representing:

First name:

Surname:

House Number / Name:

Street Name:

Town/City:

County:

Postcode:

Date of birth:

Hospital Number (if known):

ABOUT RAISING A FORMAL COMPLAINT
The law says that you should raise a formal complaint within a year of becoming aware of the problem. Sometimes, depending on circumstances, we will extend this time limit if there is good reason for the delay. If you haven't been able to complain to us within a year of becoming aware of the problem, please tell us why you did not complain sooner:

DETAILS OF YOUR INFORMAL CONCERN OR FORMAL COMPLAINT
Tell us what your concern or complaint is about – tell us what happened, when, where and who was involved

Please provide a bullet-point list of your questions - The Patient & Family Relations Officer will discuss and confirm these with you.:

Please tell us how you, or the person you represent, have been affected by what has happened.

What would you like to happen? What outcome would you like?

Please leave this field empty.