Helplie: 0161 923 6602 1 Complait form The quickest ad easiest way to complai about a doctor is to use our olie form at www.gmc-uk.org/complait. Whe you submit your complait olie, we will email you with your referece umber. If you ca t use our olie form, please use this form to make your ow complait about a doctor, or to complai o someoe else s behalf. If you eed help, please read our booklet How to complai about a doctor at www.gmc-uk.org/ cocerspublicatios, call us o 0161 923 6602 or visit www.gmc-uk.org/cocers. Please fill i the form i blue or black ik, i CAPITALS, givig us as much detail as you ca. The iformatio you will eed to complete this form Before fillig i this form, you may fid it useful to gather the followig iformatio. The date (or approximate date) that the icidet you wish to report took place. Details of the icidet for example, where did the icidet happe? What do you feel the doctor has doe wrog? What happeed to you or the patiet as a result of the doctor s actios? If you have already complaied to aother orgaisatio, such as your local surgery or hospital, it will help us if you ca provide details of who you complaied to ad what the outcome was. The ame of the doctor who you wat to complai about. The doctor s uique seve-digit GMC referece umber that we use to idetify them. All doctors registered to work i the UK have a umber ad it will help us to process your complait more quickly. You ca fid a doctor s GMC referece umber by: askig your doctor searchig our olie medical register at www.gmc-uk.org/lrmp checkig other healthcare websites you ca fid details of these o our website at www.gmc-uk.org/idetifyadr. If you have complaied to the GMC before about this matter Please put your cocers i writig, quotig the referece umber we previously gave you, the email them to us at practise@gmc-uk.org or write to us at the Geeral Medical Coucil, Fitess to Practise Directorate, 3 Hardma Street, Machester M3 3AW. Please do ot submit a ew complait i this istace. If you caot fid or remember the referece umber, please tell us the ame of the doctor ad/or the date whe you first made the complait.
Your details Helplie: 0161 923 6602 2 Title (Mr, Mrs, Ms, etc) Full ame Address Home phoe umber Mobile umber Email address Date of birth Geder Your GMC referece umber, if you are a doctor M/F Reasoable adjustmets We are committed to makig reasoable adjustmets, i lie with the Equality Act 2010, to help disabled people to complai about a doctor. Please tell us if you eed ay reasoable adjustmets, such as receivig this form or iformatio about the complaits procedure i a alterative format (eg large prit or audio). Who you are For example: patiet, patiet s paret, patiet s guardia, patiet s spouse or parter, patiet s relative, patiet s legal represetative, patiet s fried, cocered member of the public, cocered doctor or aother health professioal. I am the If you are ot the patiet, please give us more iformatio about them. Title (Mr, Mrs, Ms, etc) Patiet s full ame Date of birth Geder M/F
Doctor s details Helplie: 0161 923 6602 3 Please give the details of the doctor(s) you are complaiig about. First doctor s details Doctor s full ame Orgaisatio s ame Departmet Orgaisatio s address Please give ay other iformatio that you thik might help us to idetify the doctor such as the type of doctor or the doctor s specialty. Geder M/F GMC referece umber Secod doctor s details Doctor s full ame Orgaisatio s ame Departmet Orgaisatio s address Please give ay other iformatio that you thik might help us to idetify the doctor such as the type of doctor or the doctor s specialty. Geder M/F GMC referece umber If there are more tha two doctors ivolved, cotiue o a separate sheet ad attach it securely to this form. Please tick here if you have cotiued o a separate sheet.
Icidet details Helplie: 0161 923 6602 4 Icidet date Whe did the icidet occur? (Please estimate if you are usure.) If there was a series of icidets, please provide us with the most recet date. You ca provide other relevat dates i the Summary of your complait below. We ca t usually ivestigate cocers about evets that took place more tha five years ago. If the icidet date is more tha five years ago, please explai why you did ot raise it with us previously. We eed to uderstad this before we ca take ay further actio. Icidet locatio(s) Please give details of where the icidet(s) occurred. For example, if the icidet happeed whe you were receivig medical treatmet, this could be the doctor s surgery or hospital. Summary of your complait Please give further iformatio about your complait. For example, what do you feel that the doctor has doe wrog? What happeed to you or the patiet as a result of the doctor s actios? If there were several icidet dates, please provide the dates here. Please iclude as much iformatio as you ca remember. If you are complaiig about more tha oe doctor, please make clear what you thik each doctor has doe wrog. Cotiued
Helplie: 0161 923 6602 5 Cotiued If ecessary, cotiue o a separate sheet ad attach it securely to this form. Please tick here if you have cotiued o a separate sheet. Witess iformatio If ayoe witessed the icidet, please give their ame(s) ad explai what you thik they may have see or heard. Supportig documetatio If you have ay documets that you feel are relevat to your complait, please eclose copies ad list them here. If you ask us to, we will retur ay origial documets you sed oce we have copied them.
Helplie: 0161 923 6602 6 Further iformatio about your complait If you have already complaied about this matter to your doctor s surgery or hospital, the local trust, health board or aother regulatory body, please give the details below. If ot, please go to the Coset ad declaratio sectio. First orgaisatio s details Cotact s ame Cotact s email address Orgaisatio s ame Departmet Orgaisatio s address Please give brief details of their respose to your cocer, icludig ay verbal feedback that you may have bee give. Secod orgaisatio s details Cotact s ame Cotact s email address Orgaisatio s ame Departmet Orgaisatio s address Please give brief details of their respose to your cocer, icludig ay verbal feedback that you may have bee give. If you have complaied about this matter to more tha two orgaisatios, cotiue o a separate sheet ad attach it securely to this form. Please tick here if you have cotiued o a separate sheet.
Supportig documetatio Helplie: 0161 923 6602 7 If you have ay documets, such as a copy of the complait letter or the respose that you received from the healthcare provider that you feel are relevat to your complait, please eclose copies ad list them here. If you ask us to, we will retur ay origial documets you sed oce we have copied them. Coset ad declaratio We would like your permissio to tell the doctor(s) cocered, their employers ad other relevat idividuals or orgaisatios about your complait if ecessary to progress a ivestigatio. I some circumstaces we ca share your complait without your coset, but would prefer to have your agreemet. Where this is ot the case, you eed to be aware that, if you do ot give your permissio, we may ot be able to take your cocer ay further. Please tick the box below to give us your permissio to share your complait i order to deal with your cocers or to assist aother orgaisatio or idividual to do so. Coset ad declaratio statemets I agree that the GMC ca tell the doctor(s) cocered, their resposible officer/suitable perso, their employers ad ay other relevat idividuals or orgaisatios about my complait, ad ca share ay iformatio I provide i coectio with it, i order to make equiries ad/or carry out a ivestigatio i relatio to the matter. I also agree that the GMC ca pass the complait to aother appropriate body or idividual (icludig the doctor s resposible officer/suitable perso) if it is ot (or ot solely) a matter for the GMC. Yes No I agree to co-operate with the GMC s ivestigatio icludig, for example, providig a statemet. Yes No I declare that all the iformatio I have give i this form is to the best of my kowledge complete ad accurate. Sigature If you are the patiet, please also complete the followig Date I agree that the doctor(s) cocered, their employers or other relevat idividuals or orgaisatios ca provide the GMC with ay iformatio about me that the GMC eeds to cosider my complait, icludig my medical records. Yes No Sigature Date
Medical records coset Helplie: 0161 923 6602 8 To cosider your complait we may eed to get copies of the patiet s medical records. To do this, we eed to have the coset of the patiet, their guardia or legal represetative. We also eed you to tell us the ame(s) of the hospital or surgery holdig the records, that relate to the matter beig complaied about. We may eed to share these records with the doctor as part of our ivestigatios. We may ot eed copies of the medical records but, if we do, it will save time if you give us your coset at this stage. Orgaisatio s ame where records are held Orgaisatio s address (if kow) (if kow) If relevat medical records are held i more tha oe locatio, please cotiue o a separate sheet ad attach it securely to this form. Please tick here if you have cotiued o a separate sheet. If you are the patiet I give permissio for the GMC to obtai copies of my medical records for the period the GMC cosiders relevat to this complait. Your ame Sigature Date Date of birth If you are the ext of ki or legal represetative for a patiet who is youger tha 16 years or has died Your ame Relatioship to the patiet I give my permissio for the GMC to obtai copies of the medical records for the patiet for the period the GMC cosiders relevat to this complait. I cofirm that I have the legal authority to give this permissio. Patiet s ame Patiet s date of birth Patiet s date of death (if applicable) Your sigature Date
Checklist Helplie: 0161 923 6602 9 Please make sure that you have: checked that all pages of this form are filled i ad additioal pages are eclosed give us your ame ad, if possible, a daytime phoe umber give us as much iformatio about the doctor(s) cocered as you ca described your complait as fully as possible eclosed ay letters about your complait that you have set to, or received from, ay other orgaisatio you have complaied to completed the Coset ad declaratio sectio. What happes ext? Whe you have completed this form, please sed it to: Fitess to Practise, Geeral Medical Coucil, 3 Hardma Street, Machester M3 3AW. We will review your complait ad tell you withi two weeks whether we will be ivestigatig it further. If we are uable to ivestigate, we will explai why. Thak you for takig the time to complete this form. The GMC is a charity registered i Eglad ad Wales (1089278) ad Scotlad (SC037750) Code: GMC/PCF/0916