Complaint Form - Patient Representative

If you want to complain about your own NHS care, please complete the patient form instead.

To enable NHS Cheshire and Merseyside ICB to progress your complaint, please provide the following information.

Patient forename

Patient surname

Patient date of birth

Day

Month

Year

Patient home address

Including postcode

You can enter up to 250 characters

Patient registered GP practice

We also need this information to identify if you have approached the correct ICB

Patient NHS number (if known) (optional)

Enter the 10-digit number without spaces

Patient telephone number

Patient email address

Confirm patient email address

Now we need information about you acting on behalf of the patient.

Your full name

Your telephone number

Your email address

Confirm your email address

If you have a preferred method or special need for communication, please state what that is.

Preferred communication method (optional)

Authority to act

This section is to be used when a representative (the patient representative) is acting on behalf of someone else (the patient), in connection with a complaint regarding a healthcare provider commissioned or provided by NHS Cheshire and Merseyside ICB.

If you have the authority to act on behalf of the patient, please tick the box(es) which apply.

I am the Attorney for the patient under Lasting Power of Attorney (LPA) which is registered with the Office of the Public Guardian for: (optional)

Health & Welfare

Property & Financial Affairs

I have been appointed by the Court of Protection as Deputy for the patient, to make decisions on: (optional)

Health & Welfare

Property & Financial Affairs

I am the Executor of the Will of the deceased (optional)

None of the above (optional)

Please upload a digital copy of the LPA(s)/Court Order, as appropriate. If you answered None of the above, please upload consent from the patient, such as an email or letter confirming that you can act on their behalf.

File upload (optional)

Supported file types: .pdf, .docx, .xlsx, .txt, .png and .jpg

Consent

Important note: Should the ICB not receive appropriate consent, we will be unable to progress further and will close the case.

We reserve the right to contact the patient to ensure that they understand what information is to be shared with the parties involved.

I understand that in providing consent, NHS Cheshire and Merseyside ICB will be disclosing information to me as the representative of the above named patient, which may contain sensitive personal medical details about the patient in the course of resolving my complaint.

In addition, I understand that NHS Cheshire and Merseyside ICB will contact the NHS provider I am complaining about and share all the information I have provided, to enable an investigation into my concerns to take place.

I also understand that this may necessitate the divulging of personal information, medical notes and records of my treatment to NHS staff (clinical and non-clinical) involved in the management of my complaint case, and I hereby consent to that disclosure.

I also understand that this information might be used for other purposes, such as monitoring the complaints process and/or improving service quality, but that only anonymised information will be used. If identifiable data is needed for other purposes, then my consent will need to be obtained separately.

Note: If you wish to withdraw your consent at any stage of the complaint process, please contact your complaint case handler, once details of this have been provided to you.

Raising a complaint with the use of AI

We want to hear about your complaint in your/patient’s own words. We know some people find Artificial Intelligence (AI) tools such as ChatGPT helpful when completing forms. Please be aware that AI-generated text can sometimes make complaints too complicated or include legal references that are not relevant. This may increase the time it takes us to review your complaint, or we may need to ask you to resubmit it. We follow the Parliamentary Health Service Ombudsman – Good Complaint Handling standards. Information about using AI to raise a complaint has been taken from their guidance.

When you bring a complaint to us, we need to understand your/the patient’s personal experience and how the issues have affected you/the patient. Simple, clear language that explains what happened to you will always be more helpful than complicated, formal writing.

We know some people find AI tools useful to support with their writing. It is important to remember the risks of sharing your information with AI tools. Providers of these tools may use it to train their AI systems and may process it in different countries. Avoid entering sensitive personal information unless you are confident about how it will be used and protected.

Here are some suggestions to get the best results from AI tools while making sure it still sounds like you and your complaint:

Keep your prompts focused on your experience and how it made you/the patient feel. A prompt is a question or instruction that you type into an AI tool to tell it what you want help with. You can use these examples (from the PHSO website) of useful AI prompts to help with your complaint.
Do not ask AI to add legal arguments, use formal legal language or reference laws to try and make your complaint sound more ‘official’.
It is important to check any AI-generated text to make sure it reflects your own/the patient’s personal experience and contains accurate facts.

Please provide details of your complaint

You can enter up to 2000 characters

If you wish to add any attachments, such as copies of correspondence, please do so here. However we ask that you do not send any photographs of bodily parts.