Concerns form

The purpose of this form

This form is for you to raise a concern about a doctor to the General Medical Council. You can use this form to raise your own concern about a doctor, or to raise a concern on someone else’s behalf.

You do not have to use this form but, if you do, it will help us to consider your concern quickly. If you need help, please see our web guidance on how to raise a concern, or call us on 0161 923 6602.

Accessible Word document

This form contains a series of tables with header rows. All tables have a two-column format with the question in the first column and space for the answer in the second column.

If you are using a screen reader, use the Tab key after the header to move to the question. Then tab once after the question to move to the empty cell where you can type your answer.

The information that you will need to complete this form

Before filling in this form, you should try to gather the following information:

  • The name of the doctor who you wish to raise a concern about.
  • The doctor’s unique seven-digit GMC reference number that we use to identify them. All doctors registered to work in the UK have a number and it will help us to process your concern more quickly.

You can find a doctor's GMC reference number by:

  • asking your doctor
  • searching our online medical register
  • checking other healthcare websites - you can find details of these on our website.
  • The date (or approximate date) that the incident that you wish to report took place.
  • Details of the incident – for example, where did the incident happen? What you feel that the doctor has done wrong? What happened to you or the patient as a result of the doctor’s actions?
  • If you have already complained to another organisation such as your local surgery or hospital, it will help us if you can provide details of who you complained to and what the outcome was.

If you have complained to the GMC before about this matter

Please put your concerns in writing quoting the reference number we previously provided and email them to us at r write to us at the General Medical Council, Fitness to Practise Directorate, 3 Hardman Street, Manchester M3 3AW.

Please do not submit a new concern in this instance.

If you cannot find or remember the reference number, please tell us the name of the doctor and/or the date when you first raised the concern.

Your details

About you

Question / Answer
Title
First name
Family name
If you are a doctor, please give us your GMC reference number
Address line 1
Address line 2
City or town
County or region
Postcode
Country
Home phone
Mobile number
Email
Date of birth (dd/mm/yyyy)
Gender
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Reasonable adjustments

Question / Answer
We are committed to making reasonable adjustments, in line with the Equality Act 2010, to help disabled people to complain about a doctor. Please tell us if you need any reasonable adjustments, such as receiving this form or information about the concerns procedure in an alternative format (eg large print or audio).
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Who you are

For example:

  • patient
  • patient’s parent
  • patient’s guardian
  • patient’s spouse/partner
  • patient’s relative
  • patient’s legal representative
  • patient’s friend
  • concerned member of the public
  • concerned doctor or another health professional.

Having read these examples,type your answer in the box after the statement ‘I am the’.

Question / Answer
I am the
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If you are not the patient, please give us more information about them.

Question / Answer
Title
Patient’s first name
Patient’s family name
Date of birth (dd/mm/yyyy)
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Doctor’s details

Please give the details of the doctor(s) you are complaining about.

First doctor's details

Question / Answer
GMC reference number
Family name
First name
Other name(s)
Gender
Organisation name
Department
Address line 1
Address line 2
City or town
County or region
Postcode
Country
Type of doctor or doctor’s specialty
Please give any other information that you think might help us to identify the doctor.
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Second doctor's details

Question / Answer
GMC reference number
Family name
First name
Other name(s)
Gender
Organisation name
Department
Address line 1
Address line 2
City or town
County or region
Postcode
Country
Type of doctor or doctor’s specialty
Please give any other information that you think might help us to identify the doctor.
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If there are more than two doctors involved please continue on a separate sheet (if filling in a printed form) or continue in the space below (if completing the electronic version of this document).

Incident details

Incident date

When did the incident occur? (Please estimate if you are unsure.)

If there was a series of incidents, please provide us with the most recent date.

You can provide other relevant dates in Summary of your concern.

Question / Answer
Incident date
(please use the format dd/mm/yyyy)
We can't usually investigate concerns about events that took place more than five years ago. If the incident date is more than five years ago, please explain why you did not raise it with us previously. We need to understand this before we can take any further action.
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Incident location(s)

Question / Answer
Please give details of where the incident(s) occurred. For example, if the incident happened when you were receiving medical treatment,this could be the doctor's surgery or hospital.
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Your concern

Question / Answer
Please tell us about your concern.
  • Tell us what you feel the doctor has done wrong, what happened to you or the patient as a result of the doctor’s actions and when and where this happened.
  • If the incident happened across several dates, please include all dates.
  • If you are raising a concern about more than one doctor, please make clear what you think each doctor has done wrong.
Please give as much information as possible about your concerns – this is what we will use to initially assess your concern.
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Witness information

Question / Answer
If anyone witnessed the incident, please give their name(s) and explain what you think they may have seen or heard.
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Supporting documentation

Question / Answer
If you have any documents that you feel are relevant to your concern, please enclose copies and list them here. If you ask us to, we will return any original documents you send once we have copied them.
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Further information about your concern

If you have already complained about this matter to your doctor's surgery or hospital, the local trust, health board or another regulatory body, please give the details below. If not, please use the right cursor to go to the How we use your information section.

First organisation's details

Question / Answer
Contact’s name
Contact email address
Organisation’s name
Department
Address line 1
Address line 2
City or town
County or region
Postcode
Country
Please give brief details of their response to your concern, including any verbal feedback that you may have been given.
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Second organisation's details

Question / Answer
Contact’s name
Contact email address
Organisation’s name
Department
Address line 1
Address line 2
City or town
County or region
Postcode
Country
Please give brief details of their response to your concern, including any verbal feedback that you may have been given.
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Please continue on a separate sheet if you have complained about this matter to more than two organisations.

Supporting documentation

Question / Answer
If you have any documents, such as a copy of the complaint letter or the response that you received from the healthcare provider that you feel are relevant to your concern, please enclose copies and list them here. If you ask us to, we will return any original documents you send once we have copied them.
Please note: In line with our information security guidelines, we only return any digital media you send to us – such as DVDs, CDs and USBs – in exceptional circumstances. We can send you a copy of the information using our secure file transfer system. But to avoid the risk of erroneous data disclosure, we don’t generally return this information through the post.
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How we use your information

When we receive a serious concern about a doctor, in order to protect the public, we have a legal duty underthe Medical Act to assess if the doctor may pose a risk to patients or public confidence in doctors.

It’s important you understand how we’ll use your information when we’re looking into your concern.Before submitting this form, please read our publication How we use your information when considering concerns. You can find this on our website at

Here’s a summary of the main things you need to know.

Generally

We will handle your personal information with the utmost care and have a privacy policy in place to make surewe do this. You can read this at

Sharing your information

We will usually have to share details of your concern with the doctor(s) concerned and their employers. Wewill also share details with those who have responsibility for the performance of doctors, including where aconcern has been raised, so it’s important they get this information. They are called responsible officers orsuitable persons. You can find out more about their role on our website at

We may share details with other third parties if we think they can help with our enquiries.

Sometimes your concern may need to be considered by another healthcare regulator, appropriate body,person or organisation. If this is the case, we will pass a copy of your concern to them.

We will not share any information about you unless we’re required to do so or we need to do so in the interestsof protecting the public.

Requesting your information

We may need to ask a third party (such as your GP practice) for your medical records or other informationabout you. If we do, we will only request information that’s relevant to us considering your concern.

Your views on how we use your information

If you have any concerns or specific requests about how your information will be used, it’s important you tell usnow so we can take them into account. We will consider what you say, but may still have to go ahead and use yourinformation in the interests of protecting the public. If that happens we will tell you about our decision.

Question / Answer
Would you like to inform us of any concerns or make a request about how your information will be used?
If yes, please provide details:
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Once we’ve received your concern, we may need to contact you to ask for further information, for example a statement.

We value working with you to keep patients safe and your ongoing help is important to us.

Declarations

Question / Answer
yes or no
I have read the above and understand how my personal information will be used by the GMC.
To the best of my knowledge, all of the information I have given in this form is complete and accurate.
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Medical records

To consider your concern we may need to get copies of the patient’s medical records and we may need to share these records with the doctor as part of our investigations. Please tell us the name(s) of the hospital or surgery holding the records that relate to the matter you have raised concerns about.
We may not need copies of the medical records but, if we do, it will save time if you give us the information at this stage.

Question / Answer
Organisation’s name where records are held
Organisation’s address (if known)
Postcode (if known)
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Checklist

Please make sure that you have:

  • Checked that all pages of this form are filled in and additional pages are enclosed.
  • Given us your name and, if possible, a daytime phone number.
  • Given us as much information about the doctor(s) concerned as you can.
  • Described your concern as fully as possible.
  • Enclosed any letters about your concern that you have sent to, or received from, any other organisation you have complained to.
  • Completed the How we use your information section.

What happens next?

When you have completed this form, please email us at

Alternatively send a printed copy to:

Fitness to Practise
General Medical Council
3 Hardman Street
Manchester
M3 3AW

We will review your concern and tell you within two weeks whether we will be investigating it further. If we are unable to investigate, we will explain why.

Thank you for taking the time to complete this form.

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