Page 1 of 2

You are currently viewing the Consumer Report form. If you are a Clinician, please use the clinician report form to report your incident or near miss by clicking here

We ask consumers/patients to report your experiences to find out directly what went on when you, or someone you know, was in the emergency department (ED). The patient and their family/carer can often see most clearly how things could be improved or how an experience could have been prevented. This is also an opportunity for you to provide us with any feedback about what you felt went well in your care/care experience.

Your information will be combined with other reports, analysed and used to promote learning from events.

The information may be used at conferences, presentations and in research papers, however it will be de-identified to maintain your anonymity. All reporting will be anonymous and for education purposes/opportunities for learning only. To assist with this anonymity, please write Dr A or Nurse B instead of using the person’s name and hospital A.

Please enter incident details below - mandatory fields are marked with an asterisk (*).
Please select an option from the list below.

Describe what happened using clear, non-identifiable wording.

Describe the final outcome of your experience.

Describe how you think your experience could have been prevented.

Describe what you think the emergency department could have done better.

Invalid Input

Please enter your / the patient's age at the time of the experience.

Please enter the gender.

Invalid Input

Please select a date

Invalid Input

Invalid Input