Andrew Thomas MCCLEARY · Prevention of Future Deaths report

On 07 June 2021 I commenced an investigation into the death of Andrew Thomas MCCLEARY aged 38. The investigation concluded at the end of the inquest on 24 September 2024. Whilst I expressed my intentions to make this report immediately following the conclusion of the inquest, at your request, this was delayed pending the outcome of your judicial review application. Permission to bring judicial review proceedings was refused on 25 November 2025.

The conclusion of the jury inquest was: Unlawful Killing.

Andrew died due to the use of cocaine and the physiological and psychological effect of restraint. The events that led to his death occurred during the morning of 29th May 2021 and his death was confirmed at 10:37 on 30th May 2021 at Bedford Hospital South Wing after diagnosis of severe global hypoxic injury. Andrew came by his death in the circumstances proved as recorded in the attached questionnaire. Andrew was suffering from the effects of cocaine use and this more than minimally contributed to the cause of his death. The police officers and ambulance staff members in attendance failed to take reasonable steps to establish that Andrew was lacking in capacity as defined in the MCA 2005.
The police officers and ambulance staff were concerned with Andrew’s high heart rate and wanted him to go to hospital for treatment. There was no clear collaborative plan identified or clear communication on how to do this safely. When Andrew was restrained by both police officers and ambulance staff, there was a complete failure to monitor his physical and psychological wellbeing. When Andrew stated he could not breathe, this was dismissed and there was a failure to reassess the actions being taken. As stated by the East of England Ambulance Service, there was no clear collaborative plan with Andrew’s capacity to consent to the proposed transfer to hospital, if he had capacity to refuse and what the plan would be or whether he was suffering from fluctuating capacity. There was no multi-agency risk assessment prior to the use of restraint.

1) 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 Andrew.

2) There was an evident lack of 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) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.

The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.