5.5 Explain the process for reporting and referring behaviour that challenges

This guide will help you answer 5.5 Explain the process for reporting and referring behaviour that challenges.

Behaviour that challenges is behaviour that puts the person or others at risk. It can be actions, words, or patterns of conduct that cause harm, distress, or disruption. In the context of acquired brain injury (ABI), this behaviour often links to changes in the brain caused by trauma, stroke, infection, tumour, or lack of oxygen.

Common examples include:

• Aggression or verbal outbursts
• Physical violence towards people or objects
• Self-harm behaviours
• Non-compliance with rules or care plans
• Inappropriate sexual behaviour
• Restlessness or wandering

These behaviours can affect safety, treatment, and relationships. They can be unpredictable and may vary in severity from day to day. ABI can damage reasoning, impulse control, memory, and emotional regulation. This means the person may not be aware their behaviour is harmful or unacceptable.

Because of this, there must be a clear and consistent process for reporting and referring such behaviour. This ensures the right support is given, risks are reduced, and the individual’s needs are addressed properly.

Purpose of Reporting and Referring

Reporting and referring behaviour that challenges is not about blaming the person. It is about creating a record that supports care planning and reduces risk. It also allows other professionals to identify patterns in the behaviour and decide on the right interventions.

The reasons for reporting and referring include:

• Protecting the safety of the individual and others
• Recording incidents accurately for legal, medical, and safeguarding reasons
• Informing colleagues to adjust care approaches
• Triggering specialist assessment or support
• Helping managers decide on staff training or environmental adjustments

Reporting may be the first step to getting specialist input from psychologists, occupational therapists, or behaviour support teams. Without proper recording, these professionals may not have enough information to identify the cause or triggers of the behaviour.

Organisational Policies and Procedures

Every health and social care setting will have its own policies and procedures for recording and sharing behavioural concerns. Workers must follow these without deviation. Policies often outline:

• What behaviour should be reported
• The timeframe for reporting
• The people who can receive reports
• The forms or systems to use
• Confidentiality rules

The procedures are usually based on legal frameworks, such as the Care Act 2014, the Health and Safety at Work Act 1974, and safeguarding laws. Failing to follow them can place people at risk and lead to disciplinary or legal consequences.

Recognising the Need to Report

Some behaviour may be part of a person’s known condition. But behaviours that increase in frequency, intensity, or change in nature should be reported. Signs that reporting is needed include:

• The person’s actions cause harm or risk to themselves or others
• The behaviour disrupts care or treatment
• Staff cannot safely or effectively manage the behaviour in the moment
• The behaviour is new, unexpected, or escalates quickly

It is good practice to report even if you managed the incident, as this builds a complete record over time. Small behaviours can develop into bigger concerns if they are overlooked.

Immediate Actions After Behaviour That Challenges

When behaviour that challenges occurs, act to keep people safe first. Remove hazards, use de-escalation techniques, and call for help if needed. Once the situation is under control:

• Check for injuries and give first aid if required
• Provide reassurance to the person, and to anyone affected
• Ask for help from senior staff if you need support

Only after safety is restored should you make a full report. Reporting should be factual, accurate, and timely.

The Reporting Process Step by Step

The precise process will depend on your workplace, but most organisations follow similar steps:

Record details immediately in the incident log or behaviour monitoring tool. Do this as soon as possible while details are fresh.

Describe the behaviour factually. Avoid personal opinions or labels. Write exactly what was seen or heard.

Include key information:

• Date and time of incident
• Location
• Names of those involved and any witnesses
• What happened before, during, and after
• The person’s emotions or communication
• Actions taken and by whom
• Any injuries or damage

Report to the correct person. This may be a manager, team leader, nurse in charge, or safeguarding officer.

Follow up if needed. This could include completing a body map for injuries or writing a safeguarding report.

Reports may be written on paper forms, entered into an electronic recording system, or both. Always use the format required in your workplace.

Factual and Objective Recording

Recording must be factual. Describe actions rather than assumptions. Avoid using terms like “aggressive” without explaining what was done. For example:

• Write: “The person shouted loudly and struck the wall with a closed fist.”
• Do not write: “The person became aggressive.”

Neutral, clear recording reduces the risk of misinterpretation and helps other professionals analyse the behaviour accurately.

Confidentiality in Reporting

All written or verbal reports should protect the person’s identity, unless sharing it is part of the agreed procedure. Only share reports with those authorised to receive them.

This means:

• Never discuss the incident in public areas
• Keep written reports secure and stored according to policy
• Only use the person’s full name in official reporting channels, not casual conversation

Breaking confidentiality could breach the Data Protection Act 2018 and cause harm to the person’s dignity and privacy.

Referring Behaviour That Challenges for Acquired Brain Injury

Referral happens after reporting, when the information is passed to another professional or team who can assess and manage the behaviour. In ABI cases, referral might be to:

• A clinical psychologist
• A neuropsychologist
• A psychiatrist
• A behaviour support specialist
• A neurologist
• Safeguarding adults team
• Multi-disciplinary team (MDT) meetings

Referrals must be made according to organisational policy. Some will require a manager’s approval, others might allow direct referral if urgent. The key is that you do not ignore patterns of behaviour that need investigation.

How to Make an Effective Referral

An effective referral:

• Provides a factual, detailed record of the behaviour
• Includes previous reports to show patterns or triggers
• States why the referral is being made
• Explains the impact the behaviour is having on care, safety, or the person’s wellbeing
• Is directed to the correct professional or service

Many referral forms will need both the worker’s and a manager’s signature. Always double-check the form before it is sent. Missing details can cause delays.

Timescales for Reporting and Referring

Reporting should be done as soon as possible after an incident. Many organisations require reports before the end of the shift. Referrals may take longer, depending on urgency, but urgent referrals should be made immediately after the incident is recorded.

If the behaviour involves violence, safeguarding concerns, or serious injury, report and refer without delay. Call emergency services if there is an immediate threat to life or safety.

Multi-Disciplinary Team Involvement

For people with ABI, behaviour that challenges often requires input from a range of professionals. The MDT may include doctors, nurses, therapists, psychologists, and social workers. Your report and referral trigger the involvement of these professionals.

The MDT can:

• Assess the causes of behaviour
• Review medication
• Suggest new support strategies
• Provide input into risk assessments
• Offer specialist training to staff

Your detailed reports help the team see patterns and make decisions backed by evidence.

Follow-Up After Referral

Once a referral is made, your role may include:

• Continuing to record behaviour incidents
• Monitoring changes after new strategies are introduced
• Liaising with specialists and updating them if behaviour changes again
• Sharing information with other team members within your workplace

Following up maintains a full picture of the person’s progress and whether interventions are working.

Barriers to Reporting and Referring

Sometimes, behaviour is not reported or referred because:

• Staff think it is part of the person’s normal behaviour
• Staff believe it will make no difference
• Lack of time during busy shifts
• Fear of being blamed for the incident
• Uncertainty about the procedure

These barriers put people at risk. Training and clear communication can help overcome them. Workers should be encouraged to report without fear of blame.

Good Practice Tips

To support effective reporting and referring:

• Keep your knowledge of policies up to date
• Record incidents factually and promptly
• Share concerns with your senior as soon as they arise
• Look for patterns over time
• Ask for additional training if unsure about procedures
• Use active listening when colleagues tell you about incidents

Good reporting is part of professional accountability and protects everyone involved.

Final Thoughts

Reporting and referring behaviour that challenges in people with acquired brain injury is a key responsibility in health and social care. It protects safety, supports effective care, and ensures that the right people get involved at the right time.

When incidents are recorded and referred properly, it becomes easier to spot patterns, understand triggers, and provide suitable interventions. This does not just benefit the individual but also creates a safer and more supportive environment for staff, families, and other service users.

If you approach reporting and referring with accuracy, respect, and prompt action, you contribute to better care outcomes and uphold your professional standards. A good report and timely referral can make a real difference to how a person with ABI is supported and how their quality of life improves.