Beyond the Risk Assessment: Enabling Independence After Brain Injury
by Laura Hartley
The role of occupational therapy in positive risk-taking: assessing, managing and mitigating risk to support meaningful rehabilitation.
Following an acquired brain injury, balancing independence and safety is often one of the most complex aspects of rehabilitation. Cognitive, physical, behavioural and emotional changes can affect an individual's ability to undertake everyday activities, sometimes creating significant risks in situations that were previously routine. Occupational therapists have an important role in understanding how these changes affect functional performance and identifying practical ways to support participation in meaningful activities.
Central to this work is positive risk-taking: a deliberate, structured approach in which the potential benefits of an activity are weighed against its risks, and the person is supported to take part with safeguards matched to their needs. The aim is not to eliminate every risk, which is rarely achievable, but to understand, manage and mitigate risk sufficiently to enable meaningful participation.
RCOT's guidance, Embracing risk; enabling choice (2018), adds that "positive" describes the outcome of taking a risk, not the risk itself. It also treats managing risk as a statutory and regulatory duty, and notes that when it is done in partnership with the person, the process can enable participation rather than act as a barrier.
Understanding Risk in the Context of Everyday Function
After brain injury, risk is often embedded in daily activities such as preparing a meal, crossing a road, managing money or returning to work. Understanding it, means looking beyond a diagnosis or individual impairment. Occupational therapists take a biopsychosocial approach to occupational performance, how well a person can carry out the activities that they need or want to do. This depends on the interaction between the person (physical, cognitive, emotional and social factors), the task (occupation) and the environment.
Occupational performance or function is optimal when these three elements fit well and risk is minimised. After brain injury, physical, cognitive or behavioural changes, social vulnerability or an unsupportive environment can create a mismatch with tasks that were once managed safely.
For example, a client with impaired attention and cognitive fatigue, may find a previously familiar walk to a local shop, becomes a high-risk situation. With slower information processing and more competing demands on their attention, they may forget to check for traffic or misjudge the speed of an oncoming car and rush hour makes the environmental demands even more challenging.
Occupational therapists therefore consider not only whether an individual can perform an activity, but whether they do it consistently, appropriately and with an acceptable level of risk in their everyday environment, taking into consideration intrinsic and extrinsic factors. Occupational therapists must therefore assess risk during every session and for experienced therapists this often becomes second nature.
Assessment as an Ongoing Clinical Process
Complex brain injury requires an ongoing assessment process, that may include cognitive and perceptual assessment, functional observation, activity analysis and discussion with the wider rehabilitation team. This approach helps identify patterns of performance and associated risks that may not become apparent during a single assessment session.
For example, a client who wants to return to cooking may clearly explain the steps involved during a quiet appointment or successfully prepare a hot drink on the ward, however, they may find it difficult to plan, organise and prepare a more complex meal in a busy kitchen at home.
Assessment may take place over several weeks or longer, during which the OT continually observes functional performance, evaluates risks, introduces interventions and adapts their approach in response to the individual's progress.
NICE guidance (2025) recommends in ABI combining standard cognitive tests with functional assessment, in settings and scenarios relevant to the person’s rehabilitation goals. This matters because of the “frontal lobe paradox” (George and Gilbert, 2018), whereby people with executive impairment but intact speech and social skills can perform well on structured, paper-based neurocognitive assessments, but can then struggle in everyday life. This can complicate the assessment of mental capacity and the support needed for independent living.
RCOT (2018) recommends a six-step risk enablement process. Step 3, “Assess the risk”, considers who is at risk, how likely harm is to occur, what that harm might be and what controls are already in place.
Assessment findings should therefore describe specific difficulties and the circumstances in which they occur. Describing someone as “unsafe in the kitchen” provides little direction for rehabilitation. In contrast, recording that they leave the hob unattended when distracted, have difficulty maintaining balance at the worktop, overlook items on their left or lose their place in a recipe identifies difficulties that can guide targeted intervention and risk management.
Risk Mitigation Through Occupational Therapy Intervention
Occupational therapists have a range of interventions available to support positive, proportionate risk-taking. Graded activity is especially valuable in brain injury rehabilitation, allowing individuals to develop skills and confidence through carefully structured progression. This may involve breaking activities into manageable components, introducing compensatory strategies, modifying the environment or adjusting the level of supervision and support. During a review, the OT must evaluate not only whether a strategy remains appropriate, but whether it is effective and sustainable in everyday life. Strategies that suit the early stages of rehabilitation may need to be modified as abilities develop, so regular review is essential.
Mental Capacity, Autonomy and Proportionate Decision-Making
Consideration of mental capacity is essential where brain injury affects insight, judgement or decision-making. The Mental Capacity Act 2005 tells us that capacity is decision-specific and that individuals with capacity have the right to make decisions others may regard as unwise.
Sometimes a risk for someone with capacity cannot be managed to a reasonable level and the person may choose to proceed against the OT’s recommendations (RCOT 2018). In these situations, it is important to record the discussion had and recommendations given, the person's choice, the actions taken and the rationale.
Where an individual lacks capacity for a particular decision, the appropriate best-interests framework applies, including consideration of their wishes and feelings and less restrictive alternatives. For occupational therapists, it is important that functional risk assessment, decision-making capacity and the individual's preferences are considered appropriately without treating them as interchangeable. Where capacity is in question, the OT may contribute relevant functional evidence or undertake a decision-specific assessment within their professional competence and remit.
As rehabilitation progresses, changes in cognitive function, understanding or the nature of the decision will warrant further consideration of capacity. Clear clinical reasoning and appropriate multidisciplinary involvement remain essential.
The OT's Contribution to Collaborative Risk Management
Positive risk-taking following brain injury will often require input from family members and collaboration with other professionals, especially where risks are complex or interventions need to be coordinated across different settings. The occupational therapist contributes specialist evidence about functional performance, occupational or environmental demands and the effectiveness of interventions designed to reduce risk. The OT may provide regular updates on progress as well as any emerging risks, the effectiveness of mitigation strategies and recommendations for adjusting the rehabilitation intervention plan. This communication is valuable where changes to supervision, care arrangements or opportunities for independent activity are being considered.
Where risk assessment or management tasks are delegated, the OT remains responsible for ensuring the person carrying them out is competent to do so. A formal assessment may rest with one role, but everyone involved in the person's care shares a duty of care for their safety and wellbeing (RCOT, 2018).
By sharing findings and reviewing progress collaboratively, the OT can ensure that recommendations remain realistic, practical and responsive to the client's changing abilities and needs.
Clinical Reasoning, Documentation and Professional Accountability
Robust documentation is essential to effective occupational therapy risk management, where assessment and intervention extend over a prolonged period. Rather than recording risk only at the initial assessment, the OT should maintain a clear clinical record of how the risk is understood and managed throughout rehabilitation.
It will often be necessary for records to reflect discussions with the client, case manager and wider MDT, including agreed responsibilities and review arrangements.
It is important to say that documentation must detail what happens if a risk becomes a reality. If something does go wrong, the priority is the safety of everyone involved, followed by full and timely recording and reporting; this includes near misses. In any later investigation, the care record is the main evidence that the OT's reasoning and actions were appropriate and that their duty of care was met. RCOT's Keeping records guidance (2017) gives further detail.
Managing risk is a regulatory and professional duty, not only good practice. The RCOT professional standards and HCPC guidance expect occupational therapists to enable positive risks to be taken safely where they are a necessary part of intervention. Independent practitioners should have their own policies that are compatible with legislation and professional standards, and those working on an associate or agency basis should know the risk management policies of the organisations they work with.
Enabling Independence Through Positive Risk-Taking
Risk is an evitable part of everyday life, and rehabilitation after brain injury often means supporting people to re-engage in activities that carry some uncertainty. Positive risk-taking is not independence at any cost, nor is avoiding all-risk the safest long-term option. It means understanding the person’s goals, assessing the demands of meaningful activities and identifying practical interventions that reduce risk while supporting participation.
At The OT Practice, our occupational therapists work with case managers and the wider multidisciplinary team to provide clinically robust assessments and person-centred interventions, looking beyond identifying risk, to mitigating it over time.
Ultimately, success is measured not solely by the absence of adverse events, but by how well we enable people to take part in the activities and life roles that matter to them, with appropriate safeguards in place.
References and further reading
- Mental Capacity Act 2005 and associated Code of Practice.
- Health and Care Professions Council (HCPC). Standards of Proficiency: Occupational Therapists.
- National Institute for Health and Care Excellence (NICE). NG252: Rehabilitation for Chronic Neurological Disorders Including Acquired Brain Injury (2025).
- Royal College of Occupational Therapists (2026) RCOT. Professional Standards for Occupational Therapy Practice, Conduct and Ethics.
- Royal College of Occupational Therapists (2018). Embracing risk; enabling choice: guidance for occupational therapists (3rd ed.). London: RCOT.
- Royal College of Occupational Therapists (2017). Keeping records: guidance for occupational therapists. London: RCOT.
- Department of Health (2007). Independence, choice and risk: a guide to best practice in supported decision making. London: DH.
- George, M.S., & Gilbert, S. (2018). Mental Capacity Act (2005) assessments: why everyone needs to know about the frontal lobe paradox. T_he Neuropsychologist_, 5, 59 - 66.
- Gallagher, A. (2013). Risk assessment: enabler or barrier? British Journal of Occupational Therapy, 76(7), 337-339.
- Mental Health Act 1983.
