Please fill in this short questionnaire if you are the relative or main carer of someone who died in Wiltshire over the last 12 months.
It should take no longer than 10 minutes to complete. It is confidential and your details will remain anonymous.

The information obtained from the results of the survey will be used to improve care and services for people at the end of life and their families.

Wiltshire Clinical Commissioning Group is working with hospitals, GP practices, hospices and other health care providers to understand people's experience of care and to guide any changes necessary for improvement. The survey is being undertaken in conjunction with The Patients Association, an independent health charity which is dedicated to improving patient experience. The Patients Association will receive all the surveys and prepare a report with the findings and recommendations arising from the feedback.

If you are willing to take part, please complete the questionnaire below by February 20th 2015. If you would prefer a paper copy please contact Danela Adams (Danela.adams@nhs.net or on 01380 733775) who will send you the questionnaire and a pre-paid envelope.

You will see that we also ask whether you are prepared to take part in a short telephone interview, which will help us gain an even better understanding of your experience. If you are willing to have an interview with someone from The Patients Association, please fill in the box at the bottom of the form.
Answer the questions by putting a tick in the most appropriate box or boxes

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* 1. How long had your relative been ill before he/she died?

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* 2. What was the month of death? Please mark the appropriate box

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* 3. Where did your relative die?

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* 4. What was your relationship with the deceased?

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* 5. During the last three months of life, did your relative use any of the following services? Please tick any that apply:

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* 6. What services did your relative use during the last three months of life? For each of the services used please give a rating of the care received from staff. If he/she did not use a service please mark the N/A box for not applicable.

  Excellent Good Fair Poor N/a
Hospital
Hospice
Care at home
District/Community Nurse
GP
Out of hours service*
(*By this we mean if you needed to contact a health professional for something urgent in the evening or at the weekend).

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* 7. Please use the box below to explain why you have chosen each rating. Fill in one box for each service used. What, if anything, was good about the care? What, if anything, was bad? If you did not use a service please mark the N/A box for not applicable.

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