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2
.
Is the complaint about the care or service that you received? YES / NO
If you have answered
NO
to this question, please also complete questions 3
and 4.
If you have answered
YES
to this question, please go to question 5.
3.
About the patient / service user
Who is the patient / service user:
Name: _____________________________________________________________
Address: ___________________________________________________________
__________________________________________________________________
Postcode: __________________________________________________________
Telephone number: _________________________________________________
What is your relationship to them? _____________________________________
If the person has died, please tell us the date of death here:
__________________________________________________________________
4.
Please explain why the person who has suffered as a result of the problem is
not making the complaint themselves. We would normally expect a person to
make their own complaint if they are able to. However, you can represent
someone to make a complaint if you have their consent.
___________________________________________________________________
___________________________________________________________________
SECTION 2: Information about the organisation that you are complaining about
Please note that we can only consider complaints about providers of NHS
healthcare (which can sometimes include private suppliers where all or part of
the care is funded by the NHS). You can contact us before filling in this form if
you are not sure whether your complaint is about an organisation we can
consider – our helpline number is 0345 015 4033.
5.
Which organisation(s) are you complaining about?
Name: _Nottingham University Hospitals NHS Trust_____________________
Address: Queens Medical Centre Derby Rd, Nottingham NG7 2UH________
___________________________________________________________________
Are you complaining about a particular individual? For example, doctor,
nurse:___Whoever made the decision to only treat Nottinghamshire patients_