Andrew McLeary died in May 2021 in Bedfordshire after he rang 999 because of heart palpitations, following use of cocaine. The ambulance service requested police support at the incident and they recommend he be conveyed to hospital for assessment of his heart issues and he declined. Following professional discussion, it was suggested he should be conveyed to hospital nonetheless, supposedly on the basis that he lacked capacity to decline care and the legal basis for conveyance was subsequently claimed to be the Mental Capacity Act 2005 (MCA).
I have only just learned about this 2024 inquest because the Preventing Future Deaths report which the Coroner had intended to issue immediately after proceedings concluded was delayed. The Chief Constable of Bedfordshire Police sought to bring judicial review proceedings as a result of the findings and that application having failed on the 25th November, the Coroner has now published the report. It would be interesting to learn more about why the High Court refused permission for JR but it doesn’t change the points I need to make here.
Now, you will have spotted in the opening paragraph, there was nothing expressly mental health related in the summary of this, except to the extent some people regard consumption of or intoxication by drugs to be a mental health matter. The medical manuals are clear that “acute intoxication” can be a mental disorder, where caused by alcohol, drugs or even coffee (yes, really). The PFD notice is absent any information about how affected Andrew was by drugs – we can infer it probably wasn’t acute, for reasons we’ll get in to – but the obvious point of interest is the supposed-MCA intervention.
SO WHAT ACTUALLY HAPPENED?
The main reason for a rare unlawful killing verdict appears to be the view that MCA intervention was simply not justified at all after professionals answered the 999 call. The jury found grounds for using force under the MCA simply weren’t met and no-one had properly assessed Andrew’s capacity to take a decision, however unwise, to decline to attend hospital. After 40 minutes of attempted persuasion, police officers decided to restrain Andrew to get him to hospital for treatment and therein lies the supposed unlawfulness.
Andrew passively resisted restraint and he was taken to the ground by officers and ambulance staff in a supine position, then handcuffed. He repeatedly objected to what was happening, stating he could not breathe (which should always be a red flag alarm and should be checked) and continued attempts to resist led to a spit-hood and leg-restraints being applied, which only increased his distress and the strain on his heart. After 18 minutes of restraint, involving a total of five officers and three ambulance staff, Andrew was wheeled on a stretcher to the ambulance.
Despite the justification for restraint being to secure treatment for Andrew’s heart rate and despite witnesses at the inquest accepting the known risk of cardiac arrest from prolonged restraint, ambulance staff took no steps to monitor his heart rate or other vital signs. After a further five minutes, he was found to be unresponsive and in cardiac arrest – CPR was administered but Andrew was declared dead at 10.37am.
The jury heard the cause of death was “use of cocaine and the physical and psychological effect of restraint” and it’s interesting to note emphasis also on the psychological effects of restraint.
JURY FINDINGS
- Police and ambulance staff who attended wanted Andrew to go to hospital for treatment for his high heart rate.
- They “failed to take reasonable steps to establish that Andrew was lacking in capacity as defined in the MCA”.
- There was no clear collaborative plan or clear communication on how to do this safely and no multi-agency risk assessment prior to the restraint.
- Once Andrew was restrained, there was a complete failure to monitor his physical and psychological well-being.
The jury unanimously concluded that Andrew was unlawfully killed, finding –
- Reasonable steps were not taken to establish whether Andrew lacked capacity to decide whether to go to hospital for treatment for his heart rate;
- There was a lack of honest belief that Andrew lacked capacity and that it was in his best interests to go to hospital;
- The actions were dangerous from an objective standpoint;
- The use of force/restraint more than minimally contributed to Andrew’s death.
ASSESSING MENTAL CAPACITY
It is interesting to note, above, that “police officers decided to restrain” – this is wording from the press release by Inquest, a charity who support families of those who die in state custody. Any officers reading this will probably assume, as I will admit I did, there would have been a paramedic-driven conversation to suggest he lacked capacity, notwithstanding the jury finding that reasonable steps to establish he lacked capacity were not taken. I’m also going to guess – and it really is a guess – that the concern was not a weighted assessment of risk versus benefits, of what is the risk of acting versus what is the risk of doing nothing, or doing nothing immediate.
And remember: professionals must NOT assume a lack of capacity, until someone is assessed properly to lack it and any decision thought unwise by the professionals on the scene does not, of itself, indicate a patient lacks capacity. But police officers need to be aware that THEY must be satisfied of the need for the intervention and they are responsible for determining whether the force used can be justified under the MCA. I won’t repeat here what I’ve covered many times before, but the legal explanation of how to approach this stuff is there to be understood (and I would argue should form part of basic mental health and capacity law training for officers AND paramedics, which I’ve delivered many times and which always seems to have been found useful).
What will not work, for example, is officers saying “paramedics told me he lacked capacity and had to go to hospital”. It’s up to those inflicting legal restrictions and force on other people to fully understand the basis for doing so, including satisfying themselves there has been an assessment of capacity and understanding what the risk was of doing nothing, rather than doing a restraint on someone already experiencing heart related problems.
BEDFORDSHIRE POLICE
His Majesty’s Senior Coroner Emma Whitting, in her Preventing Future Death report also states –
“The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.”
This is what particularly alarms me about this latest report, a sense of having been here before. In January / February 2021, I was this Senior Coroner’s expert witness for the inquest after the death of Mr Briggs. Having written three different expert reports, listened to days of evidence before giving my own, I became very familiar with the details of the case. Given this PFD for Mr McCleary is directed towards Chief Constable Trevor Rodenhurst KPM, I couldn’t help but think of the Briggs PFD because Mr Rodenhurst was the person who formally replied to it in 2021, then as the Deputy Chief Constable for the force.
I had to infer, based upon reading his reply, he neither understood what had happened in the Briggs case nor the PFD itself, claiming things in his letter which were a little weird, unfortunately. His “police officers should defer …” viewpoint betrayed the reality that officers in the Briggs case in fact HAD deferred to paramedics and that’s why they ended up going awry. If they had NOT deferred to implied direction, and followed existing national guidance in policing, the medical evidence was the outcome would likely have been different because the healthcare professionals had not, in fact, had the “specialist training and focus” he imagined them to have. Evidence of that was given during the inquest hearing. It was also interesting to see how he appeared to misunderstand the relevance of a restraint related monitoring alert from the NHS, which should influence police thinking when undertaking intensive restraint.
Whether I’m correct or not about his understanding, the fact remains learning should have taken place after the Briggs case and the Coroner seems to be telling us after Mr McCleary’s inquest this doesn’t appear to have happened. Bedfordshire Police have also made comments about Right Care, Right Person being introduced since this tragic outcome in 2021 but without explaining what they think the relevance of that is – I’m struggling to see it but perhaps we’ll learn the relevance when they reply to this latest PFD (due by 20th January 2026).
The four phases of RCRP mention nothing whatsoever about intervention under the Mental Capacity Act 2005.
REMEDIATING LESSONS LEARNED
I can’t help but point this out as well:
The PFD for Briggs suggested Bedfordshire should contact someone to take advice about these matters, recommending me as having been the expert who gave evidence at the inquest. Not only did they not do that, but not a single police officer anywhere in the United Kingdom subsequently asked me to outline what I thought the key learning from this important case was. I sent a summary of that learning as I saw it, unsolicited, to the National Police Chiefs Council in 2021, so no-one could say they hadn’t been told. But neither Bedfordshire Police (the target of the PFD) nor West Midlands Police (for whom I worked at the time and who said they wanted to debrief it all) asked about the learning and neither did the National Police Chiefs Council or the College of Policing, something which I found quite remarkable, given I’d been their national mental health coordinator for five years up to 2019.
And here we are again.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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