Online Complaints Form

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This field is for validation purposes and should be left unchanged.

In relation to the concerns being raised, are you the:(Required)

Patient

Complainant

Both

The Patient

Name(Required)

Full Name:

H&C / Hospital No. (if known)

Date of Birth(Required)

Address(Required)

Line 1 Town/City County Post Code

Telephone Number:(Required)

Alternative (mobile):

Complaints made on behalf of a patient or client (known as the complainant) – can you please complete the following section in order for the Complaints Department to liaise directly with you. Please note: A Consent Form needs to be completed and signed by the Patient/Client concerned to enable the complaint to be processed.

Please can you detail why the patient/client is unable to make a complaint themselves?(Required)

The Complainant

Relationship to the patient/client:(Required)

Name(Required)

Full Name:

Address(Required)

Line 1 Town/City County Post Code

Telephone Number:(Required)

Alternative (mobile):

Do you wish to provide your email address for correspondence?(Required)

Yes

Your Email Address(Required)

About your complaint

In relation to the raised concern the patient / client’s Health and Social Care Records will be obtained as part of the investigation process. Are you happy for this to occur?(Required)

Yes

I would like further details

If there has been a delay of more than 12 months in telling us of your complaint, please state why?

Details of Complaint

Outline the background to the complaint and give a description of what you think the service failed to do, or did wrongly. Try to include as much information as you can detailing what service it relates to and any named staff. Documents may be attached. Please only attach specific items, as necessary if you feel these will support your comments.

Please Select Service Location relating to Complaint from the options below:(Required)

Altnagelvin Hospital

South West Acute Hospital

Omagh Hospital and Primary Care Complex

None of the above

Please enter Service Location relating to Complaint:(Required)

Details of Complaint:(Required)

Desired Complaint Outcome

What remedy do you hope to achieve as a result of making a complaint?(Required)

Under the terms of the Equality Act 2010, a disability is defined as a ‘physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out normal day to day activities’. We welcome complaints from people with disabilities.

We want to communicate with you in a way that meets your needs.

Do you consider yourself to have a disability?(Required)

Yes

Prefer not to say

If yes, please provide details.

Do you have any communication or support needs? E.g. documentation provided in easy read, large print, and braille or via email?(Required)

Yes