Andrew McCleary

T. Assistant Chief Constable 

Bedfordshire Police 

By E Mail Only 

Emma Whitting 

Senior Coroner for Bedfordshire and Luton 

20 January 2026 

Dear Emma Whitting, 

Regulation 29 response to Coroners’ Regulation 28 report to prevent future deaths 

in 

relation 

to 

the 

inquest 

into 

the  death  of  Andrew  McCleary 

I  write  in  my  capacity  as  Assistant  Chief  Constable  of  Bedfordshire  Police  and  in 

response to the Prevention of Future Deaths report issued to the force on 25 November 

2025.  Thank  you  for  bringing  these  matters  to  our  attention.  We  take  your  concerns 

seriously and provide our response below, but may I first extend my sincere condolences 

to the family and friends of Andrew McCleary. 

I note you have highlighted three main areas within the Regulation 28 report, which I will 

address in order below: 

1.  Concern regarding knowledge of the attending officers of the requirements of the 

Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use 

force against and restrain Andrew. 

 
 
 
 
 
 
 
 
 2.  Concern regarding awareness on the part of the attending officers of the risks / 

effects  of  using  force  against  and  restraining  Andrew  and  of  the  need  for 

collaborative planning with attending ambulance staff before doing so.  

3.  Concern regarding Andrew on the part of the attending officers both during and 

after the restraint. 

As a learning organisation, we are committed to regularly reviewing internal policies and 

procedures, as well as the training delivered to our Police Officers and have taken the 

opportunity to do so again, following receipt of your regulation 28 report. 

Response to Point 1 

I  can  confirm  that  all  frontline  Police  Officers  receive  mandatory  MCA  training  which 

includes,  the  statutory  principles  of  the  MCA  (presumption  of  capacity,  enabling 

decision-making,  respect  for  unwise  decisions,  acting  in  best  interests,  and  least 

restrictive  option),  capacity  assessments,  emergency  interventions  under  Sections  5 

and 6 MCA (including lawful authority for proportionate restraint), and the requirement 

to record decisions and rationale. Our MCA training is reinforced through scenario-based 

exercises and reference to case law, including R (Sessay) v South London and Maudsley 

NHS Foundation Trust. 

However,  Police  Officers  are  trained  to  defer  to  health  professionals  when  making 

decisions  regarding  a  person’s  capacity  status,  with  an  assumption  that  the  health 

professional has better training and experience than a Police Officer. Indeed, College of 

Policing  national  guidance  states,  “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”. 

In this situation, Police were called to assist by the East of England Ambulance Service 

(EEAST), who were already engaging with Mr McCleary. Officers applied their training and 

relied on the advice given by qualified paramedics, that Mr McCleary lacked capacity, 

and eventually used force to get him into the ambulance for the purpose of transporting 

him to hospital for treatment.  

 
 
 
 
 A specific issue raised as a result of this Inquest is that a Police Officer cannot rely on the 

capacity assessment of a health professional and must satisfy themselves of capacity 

status,  before  they  are  able  to  lawfully  apply  force.  We  have  therefore  shared  the 

circumstances of this case with the College of Policing and are currently engaging with 

them to consider what bearing this may have on current national police guidance.  

For  clarity,  Bedfordshire  Police  have  delivered  training  to  all  frontline  Police  Officers 

regarding the MCA, however, the engagement with the College of Policing is in progress.  

Response to Points 2 and 3 

Since the death of Mr McCleary we have reviewed our use of force policies, processes 

and  training.  All  Police  Officers  receive  mandatory  Personal  Safety  Training  (“PST”) 

which  includes  a  specific  element  on  dealing  with  individuals  suspected  of  being 

impaired by Acute Behavioural Disturbance (“ABD”).  

On review of the current PST training material, the ABD element has been adopted from 

the CoP ABD programme which was updated in 2023. The key learning objectives of this 

training are:  

•  Recognition: Officers learn to identify ABD as a medical emergency, noting signs 

such  as  agitation,  confusion,  excessive  sweating,  high  body  temperature,  and 

abnormal strength. 

• 

Immediate  Actions:  Call  for  ambulance  via  999  immediately;  ABD  cases  are 

never taken to custody or Section 136 suites. 

•  Risks of Restraint: Training emphasises that restraint should be avoided where 

possible; if necessary, it must be minimal and justified. Officers are taught that 

restraint increases metabolic acidosis, which can lead to sudden cardiac arrest. 

The  focus  is  on  containing  the  patient  rather  than  them  being  subject  to  long 

periods of restraint. 

•  Monitoring  During  Restraint:  Officers  are  instructed  to  continuously  monitor 

breathing, responsiveness, skin colour, and pulse, and to “take stock” regularly to 

prevent fixation error. 

 
 
 •  Multi-Agency  Collaboration:  Training 

includes  the  CAMERAS  mnemonic 

(Contain,  Ambulance,  Monitor,  Explain,  Relay,  ABD  =  A&E,  Share)  to  ensure 

effective communication and handover to ambulance crews. 

•  Legal  Considerations:  Guidance  on  lawful  authority  for  restraint  under  MCA 

Sections 5 and 6 when assisting ambulance staff for medical purposes. 

Additionally,  Bedfordshire  Police  and  EEAST  have  developed  a  Memorandum  Of 

Understanding  (“MOU”)  to  reinforce  clear  roles  and  responsibilities  of  both  partner 

agencies  in  managing  the  needs  of  patients  with  suspected  ABD  and  increasing  the 

access to rapid tranquilisation at scene via appropriately trained paramedics. This MOU 

is awaiting imminent sign-off from EEAST Clinical Best Practice Group (already signed off 

by  Bedfordshire  Police).  The  MOU  has  been  created  in  compliance  with  the  CoP  and 

Royal College of Emergency Medicine guidance.  

We have strengthened collaborative working with EEAST through the development and 

launch  of  joint  scenario  training  which  focusses  on  the  ways  in  which  Police  and 

Ambulance personnel work together during multi-agency incidents, such as in the case 

of  Mr  McCleary.  This 

improves  communication,  understanding  of  roles  and 

responsibilities and importantly, maintains focus on the wellbeing of the patient. 

All ABD incidents are reviewed jointly by Bedfordshire Police and EEAST. Recent reviews 

of  Body  Worn  Video  from  two  ABD  incidents  demonstrated  Police  Officers  and 

Paramedics  working  collaboratively  and  applying  MCA  legislation to  provide  lifesaving 

care to each patient. 

Additional points 

We acknowledge your reference to Mr Briggs’ PFD dated 21 October 2021 but note this 

post-dated  Mr  McCleary’s  death.  However,  Bedfordshire  Police  and  partners  have 

worked together since 2024 to introduce and embed the national programme of Right 

Care, Right Person (RCRP). This is of particular relevance as the core principles are that 

Police should only respond where there is a clear policing purpose and the agency with 

the right skills and legal responsibly should lead.  

 
 
 The  introduction  of  RCRP  has  significantly  reduced  the  volume  of  health  and  mental 

health related incidents that Bedfordshire Police respond to. That being said, we still find 

ourselves being called upon to provide restraint in health-based settings, in situations 

where violence and aggression is presented. This is a challenge for which we continue to 

seek  system-wide  partnership  support  to  resolve,  as  we  want  to  minimise  the  risks 

presented as a result of restraining people who are physically and / or mentally unwell. 

We also wish to prevent placing our Police Officers in such vulnerable situations, where 

their intention is to help, but they do not possess the relevant health training to do so. 

Conclusion 

In  conclusion,  Bedfordshire  Police  remain  fully  committed  to  learning  from  the  tragic 

circumstances  of  Mr  McCleary’s  death  and  to  ensuring  that  our  policies,  training  and 

operational practice continue to develop in line with national guidance, legislation and 

best  practice.  We  recognise  the  vital  importance  of  effective  multi-agency  working  in 

responding to vulnerable individuals, and we will continue to work closely with our health 

partners  to  ensure  that  those  in  medical  need  receive  the  right  care  from  the  right 

professionals.  I  trust  that  the  actions  outlined  above  provide  assurance  of  our 

commitment to safeguarding the public. 

Yours sincerely 

T. Assistant Chief Constable