Learning From Incidents: Using Post-Incident Review to Strengthen Reactive Behaviour Support
Reactive strategies are intended to be used rarely, proportionately and only when preventative approaches have failed. When incidents do occur, how organisations respond afterwards is a critical indicator of quality, governance and learning culture. Within Positive Behaviour Support, post-incident review is not an administrative task but a safeguarding mechanism that ensures reactive strategies remain lawful, effective and progressively reduced over time.
This article sits alongside work on reactive strategies and incident response and the wider principles and values of Positive Behaviour Support, focusing specifically on how services convert incidents into measurable improvement rather than repetition.
The purpose of post-incident review in PBS
Post-incident review serves several functions simultaneously. It supports the individual by ensuring their experience is understood, supports staff by providing reflective learning, and protects the organisation by evidencing lawful decision-making. Critically, it tests whether reactive strategies remain necessary, proportionate and the least restrictive option available.
Effective review processes go beyond incident forms. They triangulate staff accounts, environmental factors, support plan accuracy, and the person’s communication and presentation before, during and after the incident.
Operational example: Reducing repeat restraint in supported living
In a supported living service supporting a man with autism and a history of physical aggression, incident frequency had plateaued despite a PBS plan. Post-incident reviews identified that staff were consistently applying the reactive strategy correctly, but antecedent signs were being missed during shift transitions.
The review process led to changes in handover structure, visual prompts in the environment, and refresher coaching. Within eight weeks, incidents reduced by over 40%, without altering the reactive strategy itself.
Operational example: Safeguarding-led review following injury
In a residential service, a staff member sustained a minor injury during an incident. The post-incident review was conducted jointly by the manager and safeguarding lead. Analysis showed the reactive strategy was proportionate, but staffing deployment at the time increased risk.
Actions included rota adjustments, clearer escalation thresholds and updated risk assessments. The review outcome was shared transparently with commissioners, demonstrating learning rather than blame.
Operational example: Reviewing restrictive practices in crisis services
A crisis support service identified increased use of physical intervention during night hours. Post-incident reviews highlighted environmental triggers, limited access to senior decision-makers overnight, and inconsistent de-escalation approaches.
The service introduced on-call clinical consultation and revised night-time routines. Subsequent reviews showed both reduced incident severity and shorter duration of reactive interventions.
Commissioner expectation: Evidence of learning and reduction
Commissioners expect providers to demonstrate that incidents lead to tangible change. This includes clear records of review, actions taken, and evidence that reactive strategies are being reduced or refined over time rather than normalised.
Services unable to evidence learning may face increased monitoring or contractual challenge, even where incidents themselves are unavoidable.
Regulator expectation: Governance and assurance
The CQC expects post-incident review to feed into governance systems. This includes oversight of restrictive practices, thematic analysis, and assurance that senior leaders understand patterns and risks within services.
Reviews should show how individual incidents inform wider service learning, training and policy development.
Embedding effective post-incident review
Strong systems typically include structured review tools, defined timescales, involvement of the individual where possible, and clear accountability for follow-up actions. Reviews should be psychologically safe for staff while remaining robust and transparent.
When embedded well, post-incident review becomes a driver of quality, safeguarding and continuous improvement rather than a reactive compliance task.