In November 2024, a jury in a Bedfordshire inquest concluded that Andrew McCleary was unlawfully killed during restraint by police officers and paramedics in Luton
Bedfordshire Police, unhappy with the conclusion, sought permission from the High Court for judicial review and in November 2025, that application was rejected and the Bedfordshire Senior Coroner, Emma Whiting, published the Preventing Future Death report. She had refrained from doing so, pending the High Court outcome and we are now just beyond the fifty-six day period which the police had to reply and it has just been uploaded to the Chief Coroner’s website.
I had supposed I would just update my original post with a link to their response, but it requires a post of its own.
IS IT RCRP RELATED?
This PFD report causes me some difficulty, specifically because there is nothing about the original incident involving Mr McCleary which is Right Care, Right Person related. The PFD from Ms Whiting did not mention RCRP or seek any information about it but the final portion of the response from the Bedfordshire Assistant Chief Constable is devoted to it.
I’m struggling to see the relevance of it, frankly; and the response itself begins by pointing out Bedfordshire Police agreed they should be responding to support their colleagues in the East of England ambulance service. We’ll come back to RCRP at the end – because it’s irrelevant really, except to extent forces and governments just seem to keep bringing it up as if it explains or justifies something or anything.
A reminder: Mr McCleary died in May 2021, two months after the inquest conclusion for the inquest in to the separate death of Leon Briggs, something which was referenced in the McCleary PFD. Emma Whiting, who also presided over the Leon Briggs inquest in 2021, made mention of certain similarities in the matters of concern.
THE BEDFORDSHIRE RESPONSE
Despite insistence in the response to the PFD that Bedfordshire is “a learning organisation”, the fact remains Ms Whiting issued this latest PFD, including reference to Mr Briggs’s, precisely because she seems concerned about a lack of learning. Bedfordshire have an answer for this, obviously – they point out Mr McCleary’s death pre-dated the PFD notice after Mr Briggs’s inquest, as if to imply Mr Brigg’s death can’t be relevant because Mr McCleary died before the Briggs PFD was published in October 2021.
But his death occurred two months after Mr Brigg’s inquest during which Bedfordshire Police and their lawyers were in court every day to hear what was said in evidence, including by expert witnesses, and to hear and read the jury’s conclusions. It’s not like the Briggs PFD content in October 2021 was any kind of surprise at all – they’d heard it all said in court over several weeks.
Mr McCleary’s unlawful killing was due to misapplication of the Mental Capacity Act 2005 by both emergency services, leading to unjustified, disproportionate restraint which contributed medically to the tragic outcome. The PFD for Mr McCleary emphasised the risks of restraint and the need for proper monitoring, just as was flagged in the case of Leon Briggs, which had included findings of neglect contributing to his death. It is very much a case study in ‘lessons not learned’ and this PFD response really isn’t helping.
NATIONAL GUIDANCE
The Bedfordshire ACC cites the College of Policing’s national guidance on the Mental Capacity Act 2005 within the Mental Health Authorised Professional Practice. It concerns the requirement for officers to ‘defer’ to the expertise of healthcare professionals and in the case of Mr McCleary, the ambulance service had requested police support –
“In situations where health or social care professionals are on the scene, police should defer to their expertise and provide support as appropriate and in accordance with local protocols.”
Sounds good doesn’t it? – it makes sense, intuitively.
Those of you who remember the detail of the Briggs case outlined elsewhere on this website will remember the (then) Deputy Chief Constable of Bedfordshire, Trevor Rodenhurst responded to the PFD about his death in 2013 pointing out the importance of officers deferring to paramedics because of their supposed training and expertise. The problem being: the Briggs inquest made it absolutely clear the paramedics involved did NOT have the expertise on Acute Behavioural Disturbance you might assume they had.
Deference should not be total and it should not be blind – fully understanding police guidance is actually key and the ACC has shown us that they don’t. If they had read on and quoted a few paragraphs more, they would have seen how subsequent paragraphs qualify and contextualise that a little further –
“If police officers are the only professionals present at an incident in which questions of mental capacity are raised, they are accountable for ensuring that any assessment or intervention is lawful under the MCA.
…
Police officers may refuse a request from an Approved Mental Health Professional (AMHP), doctor or any other health care professional to restrain or remove that person where this is not the case.”
[Bold is my emphasis.]
The job of the police is not to always do as they’re told by ‘health’, but to have a professional view about the lawfulness of their actions. They may defer about medical knowledge, but they have to satisfy themselves that restraint is proportionate, lawfully, appropriate and necessary. And the evidence this is true is the PFD itself because that’s what officers did and here is a coroner saying that is something which could get more people killed in the future.
MENTAL CAPACITY ACT TRAINING
Bedfordshire insist their officer receive mandatory MCA training – and I’m definitely glad to hear it. That now invites questions about its quality and content, if this is the result of that training and we need to ask why – very precisely – their officers agreed to remove Mr McCleary by force. Paramedics suggested he receive more thorough assessment in hospital for his potential heart problems after he said he did not wish to go but what we don’t know is the nature and content of those discussions.
We don’t know what was said by paramedics to explain their view that Mr McCleary lacked capacity or how they reached agreement restraint was an unavoidable response which would be lawful in the circumstances. It may well be the case paramedics are better placed to assess that and make the medical, capacity judgement but are they better placed to make the legal decision about what is a proportionate response to the seriousness and likelihood of harm? We don’t remove people to hospital just because paramedics say so and the reverse is true: we don’t decline to do that just because a paramedics hasn’t suggested it. Plenty examples of both approaches going badly awry.
That lesson should have been learned by now.
My advice on this has always been and remains: if a paramedics says “he lacks capacity and needs to go to hospital”, one way of officers then addressing the questions arising from section 6 of the MCA, which is cited by Bedfordshire in their PFD response, would be to ask, “OK – I’ve understood your view he needs to go to hospital. What happens if we do nothing and what is the risk to him if we engage in restraint to get him there and it ends up being high-intensity and / or prolonged restraint?”
Therein lies the detail of whether restraint is a proportionate response to the likelihood and seriousness of harm. There has to be something in the jury’s findings and the coroner’s matters of concern that they were simply not satisfied the MCA applied to the situation and that Mr McCleary did, in fact, lack capacity.
RIGHT CARE, RIGHT PERSON
And so here we are again: talking about RCRP when it’s just not relevant to anything at all. It’s mention in the PFD comes straight after the observation about Mr Briggs’s PFD where the ACC swipes that to the side because of the date of publication, as if the learning wasn’t there already from the inquest and from what was made known to the force before the Coroner wrote to them formally.
Firstly, RCRP is irrelevant because we know Bedfordshire agreed their deployment was necessary. RCRP is irrelevant because we know Bedfordshire Police had not introduced RCRP in May 2021. RCRP is irrelevant because it only seeks to alter police responses to mental health related events in four domains, none of which is the Mental Capacity Act 2005. RCRP is irrelevant because however many mental health related incidents Bedfordshire have now decided against attending, that was open to them as an option more than ten years ago and it’s something covered in the College APP they were keen to partially cite, above.
The death of Mr McCleary is nothing whatsoever to do with RCRP – the response strikes me as pretty disingenuous and borderline incoherent. It doesn’t actually address the issues raised by the Coroner and just ignores the specifics. It’s an exemplar in why and how lessons claimed to have been learned are just not learned at all.
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, 2026
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.
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