Andrew McCleary
25 Nov 2025 · Coroner Emma Whitting · Bedfordshire and Luton
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of knowledge of MCA requirements
“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].”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“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.”
This report
“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].”