Formal Complaint or Informal Concern Form

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:

    How would you prefer the formal complaint to proceed:

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

    Please complete the following details about yourself:

    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

    Other Lancashire Postcode area – N-compass
    Tel: 0345 013 8208

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

    Why can't they raise the concern or make the complaint themselves?

    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:

    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: