Healthcare professional (HCP) complaint/enquiry form

If your organisation or you as a healthcare professional are unhappy about a service that North West Ambulance Service NHS Trust (NWAS) has provided or an incident which we have attended please tell us so that we can investigate and make any necessary improvements. Please use this form to record any incident you wish to make on behalf of your organisation in relation to the care we have provided, giving as much information as possible. To ensure we are able to gather the information in a timely manner please choose the exact service you are referring, choosing the risk score you believe it should be handled.

Name*
Job title*
Organisation / Practice*
CCG*
Address*
Contact number*
Email*
Date*
Date Format: DD slash MM slash YYYY
Patient details (where necessary)
Please give name, address and date of birth OR NHS number
Name
Address
Postcode
Contact number
Date of birth
Date Format: DD slash MM slash YYYY
Sex
- Male
- Female
NHS number (if available)
Date of incident
Date Format: DD slash MM slash YYYY
Time of incident

: HH

MM
NWAS incident number (if known)
Service provided by NWAS
- PES - emergency ambulance (999)
- PTS - patient transport service
- Urgent care
- VAS - voluntary aid sector (eg, St John)
Details of incident (please do not use abbreviations)
Patient outcome (without patient outcome, we cannot investigate this incident thoroughly/ in its entirety)*
File upload
Drop files here or
For associated files such as incident report forms or patient report forms
Risk score (download risk score matrix below)*

Risk score matrix

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Patient details (where necessary)

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