Concerns formThe purpose of this formThis form is for you to raise a concern about a doctor to the General Medical Council. You can use this form to raise your own concern about a doctor, or to raise a concern on someone else’s behalf.

You do not have to use this form but, if you do, it will help us to consider your concern quickly. If you need help, please see our web guidance on how to raise a concern, or call us on 0161 923 6602.

Accessible Word documentThis form contains a series of tables with header rows. All tables have a two-column format with the question in the first column and space for the answer in the second column.

If you are using a screen reader, use the Tab key after the header to move to the question. Then tab once after the question to move to the empty cell where you can type your answer.

The information that you will need to complete this formBefore filling in this form, you should try to gather the following information:

The name of the doctor who you wish to raise a concern about. The doctor’s unique seven-digit GMC reference number that we

use to identify them. All doctors registered to work in the UK have a number and it will help us to process your concern more quickly.

You can find a doctor's GMC reference number by:

o asking your doctoro searching our online medical registero checking other healthcare websites - you can find details of

these on our website.

The date (or approximate date) that the incident that you wish to report took place.

Details of the incident – for example, where did the incident happen? What you feel that the doctor has done wrong? What happened to you or the patient as a result of the doctor’s actions?

If you have already complained to another organisation such as your local surgery or hospital, it will help us if you can provide details of who you complained to and what the outcome was.

If you have complained to the GMC before about this matterPlease put your concerns in writing quoting the reference number we previously provided and email them to us at practise@gmc-uk.org or write to us at the General Medical Council, Fitness to Practise Directorate, 3 Hardman Street, Manchester M3 3AW.

Please do not submit a new concern in this instance.

If you cannot find or remember the reference number, please tell us the name of the doctor and/or the date when you first raised the concern.

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Your detailsAbout youQuestion AnswerTitleFirst nameFamily nameIf you are a doctor, please give us your GMC reference numberAddress line 1Address line 2City or townCounty or regionPostcodeCountryHome phoneMobile numberEmailDate of birth (dd/mm/yyyy)GenderEnd of section, now use the down cursor key to go to the next section.

Reasonable adjustments  Question AnswerWe are committed to making reasonable adjustments, in line with the Equality Act 2010, to help disabled people to complain about a doctor. Please tell us if you need any reasonable adjustments, such as receiving this form or information about the concerns procedure in an alternative format (eg large print or audio).End of section, now use the down cursor key to go to the next section.

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Who you areFor example:

patient patient’s parent patient’s guardian patient’s spouse/partner patient’s relative patient’s legal representative patient’s friend concerned member of the public concerned doctor or another health professional.

Having read these examples, type your answer in the box after the statement ‘I am the’.

Question AnswerI am theEnd of section, now use the down cursor key to go to the next section.

If you are not the patient, please give us more information about them.

Question AnswerTitlePatient’s first namePatient’s family nameDate of birth (dd/mm/yyyy)End of section, now use the down cursor key to go to the next section.

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Doctor’s detailsPlease give the details of the doctor(s) you are complaining about.

First doctor's detailsQuestion AnswerGMC reference numberFamily nameFirst nameOther name(s)GenderOrganisation nameDepartmentAddress line 1Address line 2City or townCounty or regionPostcodeCountryType of doctor or doctor’s specialtyPlease give any other information that you think might help us to identify the doctor.End of section, now use the down cursor key to go to the next section.

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Second doctor's detailsQuestion AnswerGMC reference numberFamily nameFirst nameOther name(s)GenderOrganisation nameDepartmentAddress line 1Address line 2City or townCounty or regionPostcodeCountryType of doctor or doctor’s specialtyPlease give any other information that you think might help us to identify the doctor.End of section, now use the down cursor key to go to the next section.

If there are more than two doctors involved please continue on a separate sheet (if filling in a printed form) or continue in the space below (if completing the electronic version of this document).

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Incident detailsIncident dateWhen did the incident occur? (Please estimate if you are unsure.)

If there was a series of incidents, please provide us with the most recent date.

You can provide other relevant dates in Summary of your concern.

Question AnswerIncident date(please use the format dd/mm/yyyy)We can't usually investigate concerns about events that took place more than five years ago. If the incident date is more than five years ago, please explain why you did not raise it with us previously. We need to understand this before we can take any further action.End of section, now use the down cursor key to go to the next section.

 Incident location(s)Question AnswerPlease give details of where the incident(s) occurred. For example, if the incident happened when you were receiving medical treatment, this could be the doctor's surgery or hospital.End of section, now use the down cursor key to go to the next section.

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Your concernQuestion AnswerPlease tell us about your concern.

Tell us what you feel the doctor has done wrong, what happened to you or the patient as a result of the doctor’s actions and when and where this happened.

If the incident happened across several dates, please include all dates.

If you are raising a concern about more than one doctor, please make clear what you think each doctor has done wrong.

Please give as much information as possible about your concerns – this is what we will use to initially assess your concern.End of section, now use the down cursor key to go to the next section.

Witness informationQuestion AnswerIf anyone witnessed the incident, please give their name(s) and explain what you think they may have seen or heard.End of section, now use the down cursor key to go to the next section.

Supporting documentationQuestion AnswerIf you have any documents that you feel are relevant to your concern, please enclose copies and list them here. If you ask us to, we will return any original documents you send once we have copied them.End of section, now use the down cursor key to go to the next section.

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Further information about your concernIf you have already complained about this matter to your doctor's surgery or hospital, the local trust, health board or another regulatory body, please give the details below. If not, please use the right cursor to go to the How we use your information section.

First organisation's detailsQuestion AnswerContact’s nameContact email addressOrganisation’s nameDepartmentAddress line 1Address line 2City or townCounty or regionPostcodeCountryPlease give brief details of their response to your concern, including any verbal feedback that you may have been given.End of section, now use the down cursor key to go to the next section.

Second organisation's detailsQuestion AnswerContact’s nameContact email addressOrganisation’s nameDepartmentAddress line 1Address line 2City or townCounty or regionPostcodeCountry

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Question AnswerPlease give brief details of their response to your concern, including any verbal feedback that you may have been given.End of section, now use the down cursor key to go to the next section.

Please continue on a separate sheet if you have complained about this matter to more than two organisations.

Supporting documentationQuestion AnswerIf you have any documents, such as a copy of the complaint letter or the response that you received from the healthcare provider that you feel are relevant to your concern, please enclose copies and list them here. If you ask us to, we will return any original documents you send once we have copied them.

Please note: In line with our information security guidelines, we only return any digital media you send to us – such as DVDs, CDs and USBs – in exceptional circumstances. We can send you a copy of the information using our secure file transfer system. But to avoid the risk of erroneous data disclosure, we don’t generally return this information through the post.End of section, now use the down cursor key to go to the next section.

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How we use your informationWhen we receive a serious concern about a doctor, in order to protect the public, we have a legal duty under the Medical Act to assess if the doctor may pose a risk to patients or public confidence in doctors.

It’s important you understand how we’ll use your information when we’re looking into your concern. Before submitting this form, please read our publication How we use your information when considering concerns. You can find this on our website at www.gmc-uk.org/your-information.

Here’s a summary of the main things you need to know.

GenerallyWe will handle your personal information with the utmost care and have a privacy policy in place to make sure we do this. You can read this at www.gmc-uk.org/privacy-and-cookies.

Sharing your informationWe will usually have to share details of your concern with the doctor(s) concerned and their employers. We will also share details with those who have responsibility for the performance of doctors, including where a concern has been raised, so it’s important they get this information. They are called responsible officers or suitable persons. You can find out more about their role on our website at www.gmc-uk.org/revalidation.

We may share details with other third parties if we think they can help with our enquiries.

Sometimes your concern may need to be considered by another healthcare regulator, appropriate body, person or organisation. If this is the case, we will pass a copy of your concern to them.

We will not share any information about you unless we’re required to do so or we need to do so in the interests of protecting the public.

Requesting your informationWe may need to ask a third party (such as your GP practice) for your medical records or other information about you. If we do, we will only request information that’s relevant to us considering your concern.

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Your views on how we use your informationIf you have any concerns or specific requests about how your information will be used, it’s important you tell us now so we can take them into account. We will consider what you say, but may still have to go ahead and use your information in the interests of protecting the public. If that happens we will tell you about our decision.

Question AnswerWould you like to inform us of any concerns or make a request about how your information will be used?

If yes, please provide details:

End of section, now use the down cursor key to go to the next section.

Once we’ve received your concern, we may need to contact you to ask for further information, for example a statement.

We value working with you to keep patients safe and your ongoing help is important to us.

DeclarationsQuestion

Answer yes or no

I have read the above and understand how my personal information will be used by the GMC.

To the best of my knowledge, all of the information I have given in this form is complete and accurate.End of section, now use the down cursor key to review the check list and find out how to submit this form.

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Medical records To consider your concern we may need to get copies of the patient’s medical records and we may need to share these records with the doctor as part of our investigations. Please tell us the name(s) of the hospital or surgery holding the records that relate to the matter you have raised concerns about.We may not need copies of the medical records but, if we do, it will save time if you give us the information at this stage.

Question AnswerOrganisation’s name where records are heldOrganisation’s address (if known)Postcode (if known)End of section, now use the down cursor key to go to the next section.

ChecklistPlease make sure that you have:

Checked that all pages of this form are filled in and additional pages are enclosed.

Given us your name and, if possible, a daytime phone number. Given us as much information about the doctor(s) concerned as you

can. Described your concern as fully as possible. Enclosed any letters about your concern that you have sent to, or

received from, any other organisation you have complained to. Completed the How we use your information section.

What happens next?When you have completed this form, please email us at practise@gmc-uk.org

Alternatively send a printed copy to:

Fitness to PractiseGeneral Medical Council3 Hardman StreetManchesterM3 3AW

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We will review your concern and tell you within two weeks whether we will be investigating it further. If we are unable to investigate, we will explain why.

Thank you for taking the time to complete this form.

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