Positive Risk-Taking: How Safe Is Safe Enough?

I once worked in a dementia service that had a workshop, with tools and practical activities. When we were going through the registration process, I was asked whether that was really safe considering the client group. I remember being so irritated by the question, because it seemed to start from the assumption that dementia somehow made the whole idea questionable!

The person who asked me with real shock, did not know if the people who would use the space had been working with tools for years, repairing, building, gardening, fixing things around the house or simply doing the sort of practical jobs that may have been part of their life. People don't suddenly lose all of that experience because they now have a diagnosis, and I let that person know this!

Of course the risks needed to be considered. I would expect that in any service. But that is different from deciding that the activity itself is inappropriate because of the type of people receiving care, and I think that's why positive risk-taking gets difficult in practice.

We are all quite comfortable with the phrase and nobody is going to stand up and say they are against choice and independence, but the difficulty arises when someone actually wants to do something that makes us nervous. That might be using tools, going out alone, having a drink, cooking, smoking, taking part in something physical, or simply making a decision we would not make for them. At that point, “keeping people safe” can start doing a lot of heavy lifting, and I get it. Providers are responsible for managing risk. Staff do not want people harmed, families worry and regulators expect services to know how to keep people safe. This is where we run the risk of removing the person’s freedom, choice and identity.

The point of a good risk assessment is not to prove that something is dangerous. Most things in life are, to some degree. It is to work out what the actual risk is, what can reasonably be done to reduce it, whether the person understands the implications, and whether the remaining risk is proportionate to what they gain from doing it. To do this we need to view the person in front of us and not their diagnosis.

Two people living with dementia may have completely different abilities, histories and levels of understanding. One may be perfectly capable of using familiar tools, another may not be. The answer should come from the individual assessment, not from a blanket view of what people living with dementia should or should not be allowed to do.

That is where services can find themselves caught in the middle. The person wants to carry on doing something that matters to them, the family may be worried about the risk, safeguarding may want reassurance that the risk is being managed properly, CQC will expect the service to be able to explain its decision, and the provider quite reasonably wants to know that the position can be defended if something goes wrong. Put these all together and it can become much easier to say no than to work out how something might be possible and keep everyone happy.

We talk a lot about person-centred care, choice and independence, but services can feel they are being pulled in the opposite direction as soon as there is a possibility of harm. The safest option for the organisation is not always the best option for the person, and sometimes the most restrictive decision is also the easiest one to explain afterwards, I see this often. The staff team really want to support the person, but the scrutiny and shocked questions, 'why on earth would you even consider this?' prevents them from doing so.

That is where I think positive risk-taking needs more than a good risk assessment. It needs a culture that gives staff confidence to support sensible, considered choices without feeling that they are one adverse outcome away from being asked why they allowed it in the first place. Because in reality people can make perfectly reasonable decisions, the risks understood, the support appropriate, and something can still go wrong. That does not automatically mean the original decision was wrong.

If someone has been involved, the risks have been properly considered, reasonable steps have been taken to reduce them and the decision reflects what matters to that person, then we should be able to confidently stand behind that decision even if the outcome is not perfect. Otherwise, we end up creating services where staff become frightened to support anything that carries uncertainty, because the safest thing for them professionally is to say no. That is not really person-centred care!

There is also a danger that we start assessing risk from the organisation’s point of view rather than the person’s. What is easiest to defend? What is least likely to generate difficult questions? But I think we also have to ask what the person loses if we say no. Very likely their independence, identity, confidence or sense of purpose, and in my eyes those are the most significant risks.

This is where advocacy comes in. The people who know the person well have a responsibility to speak up for what matters to them, particularly when someone looking in from the outside only sees the risk. A regulator, safeguarding professional or commissioner may see one part of the picture. They may not know that this person spent forty years working with tools, has always valued doing things for themselves, or becomes distressed when too much is taken away from them.

That does not mean dismissing legitimate challenge, sometimes an outside view will identify something we have missed, and we should be open to that. Equally, we should not abandon a sensible, well-considered decision simply because somebody who does not know the person is uncomfortable with it. If we genuinely know the person, understand their wishes, have considered capacity where relevant, assessed the risk properly and put reasonable safeguards in place, then part of our role is to explain that confidently and stand behind it.

I think managers and staff sometimes lose confidence at this point. They know why the decision makes sense for the person, but one raised eyebrow or one “why on earth would you allow that?” is enough to send everyone scrambling towards the safest possible option. We need to be better than that.

Person-centred care occasionally means being prepared to say, professionally and with evidence, “I understand why you are concerned, but this matters to the person, this is how we have assessed the risk, and this is why we believe supporting them is the right thing to do.”

The workshop is a good example for me. If we had simply decided that tools and dementia did not mix, it would have been very easy to justify on paper. Nobody could have accused us of taking a risk. But some of the people using that space would also have lost something that felt normal, familiar and meaningful to them.

That is why I think “keeping people safe” needs handling carefully. It sounds entirely positive, and usually it is, but it can very easily become shorthand for removing anything that makes the rest of us nervous.

And I think leaders have a responsibility here too. If we want staff to support positive risk-taking, then we have to back them when they make a sensible, defensible decision. We cannot talk about choice and independence, then make people regret supporting either of them the minute somebody asks a difficult question, that is how risk aversion grows.

The irony is that the more frightened we become of risk, the easier it is to forget that people receiving care are still entitled to make choices we may not make ourselves, and here's a thing, they are not required to live their lives according to what makes the rest of us comfortable!

Positive risk-taking is not about being relaxed about safety. It is about being confident enough to balance safety with somebody’s right to live a life that still feels like their own, and sometimes being prepared to advocate for that when other people would find it easier to say no.