Inquest finds Bedford man unlawfully killed following prolonged restraint by police and ambulance

Andrew McCleary died on May 30, 2021 after being put in a spit-hood and leg-restraints at his flat in St Andrew’s Road, Bedford.

His cause of death was the use of cocaine and the physical and psychological effect of restraint.

On the morning of his death, he had taken cocaine and called 999 for an ambulance because he was experiencing heart palpitations. The police were called by ambulance staff and the incident was filmed on the officer’s body-worn video equipment.

Andrew, aged 38, made it clear he no longer wanted to go to hospital. And after police and ambulance staff spent 40 minutes trying to persuade him to go voluntarily to hospital, to check his heart, officers decided to restrain Andrew to get him to hospital for treatment, relying upon the Mental Capacity Act (MCA).

However, the jury found the criteria for using force under the MCA were not met, nor could the witnesses at the inquest show they had applied the criteria correctly or at all.

Andrew passively resisted attempts to force him into the ambulance – as he was entitled to do in response to unlawful restraint. But officers, assisted by ambulance staff, applied increasing force in response, first taking Andrew to the ground in the supine position, then handcuffing him. Andrew repeatedly objected to what was happening.

He also stated several times he could not breathe.

Andrew’s continued attempts to resist the restraint led to a spit-hood being applied and then leg-restraints, which only increased his distress and the strain on his heart. After 18 minutes of restraint, involving five officers and three ambulance staff, Andrew was placed on a wheeled stretcher and put in an ambulance.

At this point, despite the claim Andrew needed treatment for his heart rate, ambulance staff took no steps to monitor his heart rate or other vital signs.

Five minutes later, Andrew was found to be unresponsive and in cardiac arrest. CPR was administered to no effect. Andrew was declared dead at 10.37am on May 30, 2021.

The jury found that:

Police and ambulance staff who attended wanted Andrew to go to hospital for treatment for his high heart rate. However, they “failed to take reasonable steps to establish that Andrew was lacking in capacity as defined in the MCA”

There was no clear collaborative plan or clear communication on how to do this safely and no multi-agency risk assessment prior to the restraint

Once Andrew was restrained, there was a complete failure to monitor his physical and psychological well-being

The jury unanimously concluded that Andrew was unlawfully killed, finding:

Reasonable steps were not taken to establish whether Andrew lacked capacity to decide whether to go to hospital for treatment for his heart rate

There was a lack of honest belief that Andrew lacked capacity and that it was in his best interests to go to hospital

The actions were dangerous from an objective standpoint

The use of force/restraint more than minimally contributed to Andrew’s death

Andrew’s daughter Tye McCleary said: “Nothing will bring my dad back, however the jury’s conclusions of unlawful killing has given him the justice he deserves.”

In a tribute to her father, she added: “My dad was caring, funny, loving and compassionate. He showed empathy, making people feel safe. He had a true heart of gold. He was the definition of selfless.

“Whether it was a long or short encounter, he would leave a mark on people with his infectious laugh and his contagious grin. He was like a Cheshire Cat lighting up the room with his big gold teeth.”

A spokesman for the East of England Ambulance Service said: “This was an incredibly difficult and challenging incident for the emergency workers involved. The trust has carried out a full investigation into this incident and are implementing the learning in full.

"We have noted the jury's findings at this inquest and will ensure that we learn lessons from this. We continue to offer our condolences to the family of Mr McCleary."

Dan Vajzovic, temporary chief constable at Bedfordshire Police, said: “First and foremost, our thoughts are with Andrew’s family and friends.

“In every situation, our officers work hard to protect people and keep them safe. However, it is important to remember they are not healthcare professionals. We continuously strive to improve our response to complex incidents, especially when they involve vulnerable individuals. In partnership with other agencies, we have been actively working to improve our multi-agency protocols. This includes the introduction of the national Right Care, Right Person initiative, aimed at ensuring vulnerable people receive appropriate support from the most qualified and suitable services.

“We will carefully review the findings of this inquest and seek opportunities to enhance our multi-agency response strategies. Learning from this experience will be vital as we continue to strengthen our commitment to public safety and the well-being of the communities we serve.”

Elliot Bannister of Deighton Pierce Glynn – one of the solicitors representing Andrew’s family – said: “No-one listened to Andrew when he pointed out that being surrounded by officers wasn’t helping his heart rate; no-one listened to him when he begged the police officers to let go of him; and no-one listened when he said he couldn’t breathe. Andrew’s death was a needless tragedy.”