Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Leon Briggs · 4 Oct 2021 · Emma Whitting, Bedfordshire and Luton
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
judiciary.uk/…/leon-briggs-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Leon Briggs (4 Oct 2021) · stated timescale: this year
“A revised policy is due to be signed-off this year.”
judiciary.uk/…/2021-0330-Response-from-Bedfordshire-Police_Publ…
Stated action 2 · response to Leon Briggs (4 Oct 2021) · stated timescale: 29 October 2021
“The Chief Constable met with the National Lead for restraint's team, headed by Deputy Assistant Commissioner , on 29 October 2021.”
judiciary.uk/…/2021-0330-Response-from-Bedfordshire-Police_Publ…
Stated action 3 · response to Leon Briggs (4 Oct 2021) · stated timescale: December 2021
“EEAST's Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document 'Requesting Conveyance for Patients Detained under the MHA' will be sent to you once the review and update has been completed in December 2021.”
judiciary.uk/…/2021-0330-Response-from-East-of-England-Ambulanc…
2 further stated actions are listed on the full chain page.
What recurred
- 25 Nov 2025 · Andrew McCleary · Emma Whitting · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Leon Briggs · 4 Oct 2021
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Later · Andrew McCleary · 25 Nov 2025
“There was an evident lack of knowledge and/or concern on the part 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 [the deceased].”
What happened next
No evidence found either way · stated action 3
“When a patient is brought to the ED under section 136 of the Mental Health Act; the nurse in charge and a senior clinician should review the patient with the police and ambulance crew to assess their medical needs and review their risks to self and others.”
A brief guide to Section 136 for Emergency Departments · westyorkshire-pcp.gov.uk/…/appendix-c-a-brief-guide-to-section-…
“The 24-hour clock, and when it can be extended Someone detained under Section 136 can be held for up to 24 hours while a Mental Health Act assessment is arranged.”
Section 136 & Health-Based Places of Safety Explained · learnsignal.com/…/section-136-mental-health-act-places-of-safet…
No evidence found does not mean the action did not happen.