Cheshire and Mersey NHS 111
Health Professional Feedback Form
Greater Manchester NHS 111 welcomes feedback about its services from patients, carers, health professionals
and stakeholders alike. Listening to patients and all those who interface with our services provides a valuable
learning opportunity which can be used to bring positive improvements to the quality of healthcare we provide.
Please use this form to record any feedback you wish to make, giving as much information as possible to enable
us to identify the exact part of our service you are referring to. Please email your completed form to:
nw111gtrmanchester.feedback@nhs.net
If your feedback relates to a specific patient case or incident please complete the patient / call detail information
below to enable us to identify and review the specific call.
IN CONFIDENCE
Health Professional Feedback Form
Health Professional’s details:
Name
Job Title
Organisation/Practice
CCG
Address
Telephone
Email Address
Date
Patient’s details (where necessary): Please give name, address & date of birth OR NHS Number
Name:
Address:
Postcode:
Telephone:
Sex:
Male  Female 
Date of call to C&M NHS111
Time of call to C&M NHS111 (if known)
Risk Score (see matrix below)
FOR OFFICE USE ONLY
Received:
HPF Ref No:
Response:
Date of birth:
NHS Number (If Available):
Code:
Action:
Cheshire and Mersey NHS 111
Details of Feedback:
NB If you have any details of the outcome for the patient, please can you provide a summary as this
will assist with call review
NHS 111 Investigation findings / response:
Categorisation and Complexity Risk Table
Category
Description

Serious adverse incidents

Grossly substandard care

Professional gross misconduct
Serious 5

Serious patient safety incident, including significant patient injury or death

Referral to incorrect service affecting patients (actual harm – Death/ Life Threatening)

Unsafe Scene not declared (actual harm Major injury requiring long term treatment/ Death or Life
Threatening injury)

Significant sub-standard care.

Professional general misconduct

Patient injury arising from advice provided
Major 4

Delay in accessing care due to advice provided resulting in non-permanent injury or illness

Referral to incorrect service affecting patients (actual harm – High)

Persistent failures to deliver Safety elements of Pathway Call Review Tool

Unsafe Scene not declared (actual harm Moderate injury or illness requiring hospital treatment)

Verbal abuse or discriminatory action by staff

Professional misconduct

Inappropriate advice leading to delay in care resulting in increased hospital stay

Complaints received from Members of Parliament (minimum risk score dependant on incident
Moderate 3
described)

Referral to incorrect service affecting patients (actual harm – Minor/ Moderate)

Repeated failures to deliver Safety elements of Pathway Call Review Tool

Unsafe Scene not declared (actual harm Minor injury first aid treatment needed)

Inappropriate comments / unprofessional conduct / behaviour

Inappropriate clinical care/advice

Inappropriate advice causing distress and/or loss of appointment
Minor 2

Referral to incorrect service affecting multiple patients per day (no harm)

Multiple failures to deliver Safety elements of Pathway Call Review Tool

Unsafe Scene not declared (potential or actual minor harm not requiring treatment)

Unhappiness with staff attitude

Unprofessional behaviour
Minimum 1

Inappropriate advice causing minimal disruption

Failure in transfer to secondary care causing minimal disruption

Referral to incorrect service affecting minimal patients (no harm)
FOR OFFICE USE ONLY
Received:
HPF Ref No:
Response:
Code:
Action: