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Before filling in this form we recommend that you contact our Helpline on 0845 015 4033. We can tell you if we are able to help and give you advice on the best way to make your complaint.

Once completed, you can email phso.enquiries@ombudsman.org.uk or print out the PDF version of this form below and mail to: The Parliamentary and Health Service Ombudsman, Millbank Tower, Millbank, London SW1P 4QP.

Download PDF version (3.6mb)

Download Word version (57kb)

1. Which NHS organisation and/or practitioner are you complaining about?

Who are you complaining about?

Have you complained to the organisation or practitioner?

Yes

Was your complaint made in writing?

Yes

Have you received a final reply?

Yes

Have you contacted the Healthcare Commission about your complaint?

Yes

Have you received a reply from the Healthcare Commission?

Yes

2. Have you taken or are you planning to take legal action?

Yes

3. About you

Title (Mr/Mrs/Ms etc.)

First name

Surname

Address

Postcode

Home telephone number

Daytime telephone number

If you are complaining on behalf of someone else, you must also complete Section 4, if not go to Section 5

4. Complaining on behalf of someone else (only fill this section if you are complaining on behalf of someone else)

I am making a complaint on behalf of someone else.

First name

Surname

Address

Postcode

Home telephone number

Daytime telephone number

What is your relationship to the person who has suffered as a result of the problem?

Has this person died?

Yes		Please go to Section 5
No		Please explain why the person who has suffered as a result of the problem cannot make the complaint.

Authorisation: We will need to contact the person who has suffered as a result of the problem to get their permission to investigate this complaint and to authorise the Ombudsman to obtain relevant information about the case from the organisation(s) concerned.

If the person who has suffered is not able to give their permission please explain why

5. What are you complaining about?
Describe how you - or the person you represent - have suffered.

6. What do you want the Ombudsman to do?

7. Information to support your complaint

To help us consider your complaint, we need to see all the evidence you have about it - in particular letters to and from the organisation or person you are complaining about. If you send us this information in the post we will copy this material and return the originals to you. Please indicate if you are sending additional information by post.

Yes I am sending additional information by post (Health Service Ombudsman, Gateway Team, Millbank Tower, Millbank, London SW1P 4QP).

Before investigating your complaint we will contact you to get your permission to obtain relevant papers, including your medical records, from the organisation(s) concerned.

Find out about our privacy policy

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Last updated: 5 August 2008