Insufficient training on restraint safety and MCA requirements
Bedfordshire Police received 2 coroners' reports about this hazard between 4 Oct 2021 and 25 Nov 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ Bedfordshire Police responded, stating 5 specific actions.Response (PDF) ↗Response (PDF) ↗
“A revised policy is due to be signed-off this year.”
Stated timescale: this year
“The Chief Constable met with the National Lead for restraint's team, headed by Deputy Assistant Commissioner , on 29 October 2021.”
Stated timescale: 29 October 2021
3 more stated actions in the Promises tab.
- 4 years 2 months laterClosely relatedConfidence 0.85 · high
“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].”
Original on judiciary.uk ↗ Bedfordshire Police responded.Response (PDF) ↗
- All reports to Bedfordshire Police
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2025Andrew McCleary4 years 2 months after Leon Briggs · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight shortcomings in training and awareness regarding the safe use of restraint and its medical consequences.
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.”
Original on judiciary.uk ↗ 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].”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A revised policy is due to be signed-off this year.”
Stated action · timescale: this year
“A revised policy is due to be signed-off this year.”
Stated action · 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.”
Stated action
“The College of Policing has issued updated Authorised Professional Practice (APP), and provides 'College Learn' (formerly NCALT) with regards Officer [name redacted], First Aid and Mental Health Awareness.”
Stated action · timescale: July 2021
“The National Lead for Mental Health informed Bedfordshire Police that at the NPCC National Forum in July 2021, an update was provided by Chief Superintendent of South Yorkshire Police, who is working alongside Dr (Medical Director for West Yorkshire Metropolitan Ambulance Service, and Consultant in Emergency Medicine and pre-hospital care at Mid Yorkshire Trust) on a national ABD policy.”
Stated action · 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.”
What happened next: No evidence found either way
The organisation said the guidance would be sent in December 2021, but no source confirms it was delivered or that the deadline was met.
“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.”
“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.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Bedfordshire Police at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2025 | 0.63 | 0.00 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.