Body first.

When anything is unexplained, the body question outranks

The override is simple to state and hard to hold: when a behaviour is new, unexplained, or out of character for this person, no behavioural reading is served until physical causes have been considered. In the record it is a strategy in its own right — body_first — not a caveat attached to something else.

The clinical shorthand the field uses is constipation until proven otherwise, and it is a good summary of the posture: start from the most common, most silent, most treatable causes, and make the team prove their absence rather than assume it. NICE NG11 puts physical causes first for exactly this reason.

Structuring it as an override rather than a reminder matters because the failure it prevents is a failure under pressure. Nobody forgets that pain matters on a calm day. The record has to hold the order on the day when the behaviour is loud and the shift is short.

PINCH ME at capture, opening onto a typed differential

Seven first-pass prompts sit at capture — pain, infection, nutrition, constipation, hydration, medication, environment — the learning-disability nursing checklist most UK teams already know. Each prompt is bound by an authored mapping onto the precise typed causes it covers, and behind them sits a differential of twenty-four physical causes as a typed vocabulary rather than free text.

• The mapping fails closed. A prompt with no authored mapping is an error in the system, never a guess about the person. Safety vocabularies must be unable to improvise.
• Considered is recorded as considered. A rule-out that a carer actively thought about is a positive fact in the record, which is precisely what the mortality reviews find missing after the event.
• Prompts are for the human. The seven are a first pass to make thinking fast, not a triage algorithm. Nothing is scored, ranked or concluded from them.

Three lanes, shown together, never merged

When something is off, three different kinds of knowledge matter at once, and blending them destroys all three. WellDash shows them as lanes:

• What happened now — the episode as recorded, in the carer’s own words and its typed pieces.
• What is different from this person’s usual — the departure from their own pattern, which is the only baseline that means anything for one person.
• What is known about their life — the standing facts: conditions, medications, the things that have always been true.

They are laid side by side for a human to read together. The machine does not merge them into a single verdict, because the merge is exactly where a clinician’s judgement belongs and exactly where a confident-sounding system would do the most harm.

The dechallenge: treat, resolve, dated

A synthetic example, of the kind the record holds every day: the tapping starts, the bowel clock reads five days, a laxative is given, the bowels open, the tapping stops. Each of those is a dated row, and together they are a dechallenge — the physical cause was treated and the behaviour resolved.

The reason this outranks any interpretation is that it was a test. And when the same chain has happened before, the record shows it as this person’s own repeated result rather than a hunch — which is what changes the conversation with a GP, a nurse or a panel from impression to evidence.

The clinical graph, used lawfully

A clinician-authored graph of symptom → consideration → disposition triples sits behind the body-first work. It is used in exactly two ways, and no others: as typed vocabulary, and as authored disposition edges that a human activates. Every row carries its provenance, and every render carries the line that the human decides.

• Escalation is an authored, human-activated edge armed with the evidence. The machine never routes an emergency call.
• Nothing in the graph produces a diagnosis, a probability or an instruction. It supplies the considerations a competent human would want in front of them.
• Medication sits under the same discipline: STOMP is the standing warrant that a chemical response is never the answer to a body problem — and a medication given as a response is recorded as an intervention with a before and an after, like every other response, so it can be examined rather than assumed.

Where the priority comes from

The Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD, 2013) established the scale of avoidable death in this population, and the NHS LeDeR programme has been reviewing lives and deaths since, publishing the recurring themes. Those themes are unglamorous and consistent: constipation, aspiration, sepsis, untreated pain, medication harm, and communication failures around all of them.

NICE NG11 translates this into guidance — physical causes first, before a behavioural formulation is treated as the explanation. The clocks and the differential in this system watch for what those reviews keep finding.

What this puts in front of a clinician, a family or a panel

• The rule-outs that were actively considered, with dates — the answer to “was the body checked?” that is otherwise reconstructed from memory after the event.
• The body clocks beside the behaviour, so a pattern that looked behavioural can be re-read as physical without anyone having to remember the week.
• Any dated dechallenge chain: what was suspected, what was done, what followed.
• An ambulance grab sheet that assembles from the same record — identity, alerts, conditions, medications, this person’s own deterioration signs, what helps, and the most recent logs and incidents — for the moment when a paramedic has ninety seconds and the person cannot explain.
• A personal emergency evacuation plan built from the same substrate: mobility, transfers, communication, sensory needs, and behaviour under stress.

None of these are written from scratch at the moment they are needed. They print from what was already recorded — and a field nobody recorded prints as a gap, never as a guess.

Questions, answered the way we answer them

The rest of the grammar

• An ABC whose A can be counted — the typed context and the body clocks in detail.
• The independence journey in Down syndrome — why a behaviour change at any age is a body question first.
• The four pillars — the whole grammar in one place.