Share your experience

Please use this form to register a concern/complaint/compliment about the services provided to you or on behalf of someone else by Burton Hospitals NHS Foundation Trust (including Sir Robert Peel and Samuel Johnson Community Hospitals). If you would like further advice or help with completing this form, please contact the Patient Advice and Liaison Service on Burton 01283 593110 / 01283 593182

Alternatively, if you are raising a concern/complaint and require any independent assistance or support you can contact HealthwatchStaffordshire on 0800 161 5600, Derbyshire Mind on (01332) 623732 orPOhWER Advocacy for the East Midlands on 0300 200 0084.

  1. About you:
Mr / Mrs / Ms / Miss / other (please state)
Name: ……………………………………….. Date of birth: ………………………………………..
2. Your address:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Postcode: ………………………………………..
3. Your contact details.
When is a good time to try to contact you (within working hours)?
……………………………………………………………………………………………………………..
Home tel: ……………………………………….. / Work tel: ……………………………………..
Mobile: ………………………………………….. / Email: ……………………………………………
4. Are you complaining/complimenting on behalf of yourself? YES / NO (delete as appropriate)
If YES go to section 5
If NO, please provide details of the person you are raising concerns about.
Please note we may need to gain the consent of this person or their next of kin, if they are deceased, in order to investigate and respond to any concerns raised.
Patient’s name: ……………………………………………………………………………………………………..
Patient’s date of birth: ……………………………………………………………………………………………..
Your relationship to the patient: ………………………………………………………………………………….
Patient’s address: ………………………………………..………………………………………..………………..
Home tel: ……………………………………….. / Mobile: ………………………………………………..
5. Details of complaint/compliment
Date of incident or time period involved: ……………………………………………………………
Wards/departments involved: ……………………………………………………………
Please provide details of your concerns/compliment below, including any additional information which you feel may be helpful. Please attach additional sheets if necessary.
6. Please state the specific questions/issues, which you would like us to investigate and respond to.
NB. YOU ONLY NEED TO COMPLETE THIS SECTION IF YOU ARE RAISING A CONCERN/COMPLAINT

How we will respond to the concerns you have raised

Upon receipt of your completed form, our Complaint Team will try to contact you directly to discuss with you issues regarding consent, timescales for responding to you, and how you would like to be responded to, either in writing or a face to face meeting with senior staff once our investigations are completed.

PLEASE INDICATE BELOW HOW YOU WISH TO BE CONTACTED

I would like you to write to me/ring me (delete as appropriate) to discuss this complaint and how the Trust will respond to the concerns raised.

Signed:
……………………………………………...
(complainant or person raising issues on behalf of patient/carer/visitor)
Print name: ………………………………
Date: ……………………. / Returning this share your experience form
Please either email your completed form to
Or post it to:
Chief Executive
Queen’s Hospital Burton
Belvedere Road
Burton-on-Trent
Staffordshire
DE13 0RB

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Updated March 2017