Ask, Listen, Do 2024

1. Ask-Listen-Do

This is a form for your feedback, concern or complaint.

If you want to call us instead please phone 01227 783145 and speak to a member of staff.

There was an error on your page. Please correct any required fields and submit again. Go to the first error.

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1. Please tick to say what you are writing about *

Feedback – tell us what you think (good)
Feedback – tell us what you think (bad)
A concern – tell us if you are worried or unhappy about something. Would you like us to help you sort out a problem with the
hospital?
A complaint - tell us if you told a member of staff about your concern, but they didn't help you.

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2. I am writing about (please tick one) *

What happened to me
What happened to someone I support or care for

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3. Name of hospital and service (ward or department) *

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4. When did it happen? (date or month/year) *

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5. What happened? How did it make you feel? *

Comment:

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6. What would you like to happen next? (For example would you like somebody to contact you or would you like some action taken regarding your experience?) *

Comment:

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7. What would help you in the future? *

Information in Easy Read
Having a family member or carer with me at my appointment
Give me extra time to understand the information I have been given
The doctor or nurse talks to me, not my relative or carer

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