Post-Incident Reviews That Drive Real Change: Learning, Accountability and Service Improvement
Incidents involving reactive behaviour do not end when the immediate risk subsides. The quality of post-incident review determines whether services simply record events or actively learn from them. Within Positive Behaviour Support, post-incident review is a critical mechanism for improving practice, reducing future risk and strengthening governance.
This article forms part of the Reactive Strategies & Incident Response series and aligns with the values outlined in PBS principles and values, ensuring that learning remains person-centred and rights-based.
Why Post-Incident Review Matters
Without structured review, incidents risk becoming normalised. Staff may repeat ineffective responses, restrictive practices may persist unchecked, and early warning signs may be missed.
Effective post-incident review enables services to identify patterns, challenge assumptions and strengthen proactive support.
What a Robust Post-Incident Review Should Include
High-quality reviews go beyond basic incident reporting. They examine:
- Antecedents and early indicators
- Staff responses and decision-making
- Use and justification of restrictive practices
- Environmental and systemic factors
Reviews should involve staff directly involved, managers, and where appropriate, the individual and their representatives.
Operational Example 1: Learning from Repeated Incidents
Context: A service records repeated aggression during evening routines.
Support approach: Post-incident reviews identify sensory overload linked to staffing patterns.
Day-to-day delivery: Staffing schedules and routines are adjusted to reduce pressure points.
Evidence of effectiveness: Incident frequency reduces significantly within six weeks.
Commissioner Expectation: Evidence of Learning
Commissioners expect providers to demonstrate that incidents lead to tangible change. This includes updated care plans, staff training and documented improvements in outcomes.
Services unable to evidence learning may face increased monitoring or safeguarding escalation.
Operational Example 2: Reviewing Restrictive Practice Use
Context: A young adult experiences multiple physical interventions over a short period.
Support approach: Reviews identify inconsistent staff responses and unclear thresholds.
Day-to-day delivery: Reactive strategies are rewritten and staff receive refresher training.
Evidence of effectiveness: Use of restraint declines and staff confidence improves.
Regulator Expectation: Oversight and Accountability
The CQC expects post-incident reviews to be timely, documented and overseen by senior leaders. Inspectors will assess whether reviews genuinely influence practice or exist only on paper.
Operational Example 3: Involving the Person and Family
Context: A family raises concerns following a serious incident.
Support approach: The service involves the individual and family in the review process.
Day-to-day delivery: Communication plans and proactive strategies are revised collaboratively.
Evidence of effectiveness: Trust improves and complaints reduce.
Embedding Review into Governance Systems
Effective services integrate post-incident review into quality assurance frameworks. This includes trend analysis, senior oversight and linkage to workforce development.
When used well, post-incident review becomes a driver of cultural improvement rather than a reactive compliance exercise.