Bedfordshire Police
Police / Law Enforcement
Action Taken
Bedfordshire Police has reviewed policies and procedures, provided mandatory MCA training to frontline officers, delivered refresher training, updated the Mental Health Training package, and worked with partners to introduce the Right Care, Right Person (RCRP) programme. (AI summary)
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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.
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.