Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0587, written 17 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2025 |
|---|---|
| Reference | 2025-0587 |
| Deceased | Andrew Dodds |
| Coroner | Marilyn Whittle |
| Coroner area | South Yorkshire (West) |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable, South Yorkshire Police Headquarters, Carbrook House, 5 Carbrook Hall Road, Sheffield S9 2EH 1 CORONER I am Marilyn Whittle, Assistant Coroner, for the coroner area of South Yorkshire (West) 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 8 March 2024 an investigation was commenced into the death of Andrew Herrin Dodds. An inquest started on 6 November 2025 and concluded on 7 November 2025. The cause of death was: 1a 1b . 4 CIRCUMSTANCES OF THE DEATH Andrew Herrin Dodds was assessed by mental health services at Northern General Hospital on 10 August 2023 after expressing suicidal thoughts. He was discharged and referred to the alcohol care team, GP primary mental health team and provided with details of CRUSE, Andy’s Man Club and IAPT. Andrew then self referred to the single point of access and was accepted for further crisis assessment. He was deemed high risk and reported a plan to end his own life. He was assessed at the Longley Centre and agreed to further assessment by the Home Treatment Team. On 16 August he attended the Longley Centre but left before he was seen. Sheffield Health and Social Care (SHSC) were concerned as they were unable to contact him and reported this to South Yorkshire Police. Andrew then later contacted SHSC and made an appointment to attend the next day. He did not attend the appointment the next day and his friend stated he had left that morning. SHSC contacted SYP as they 1 were unable to contact him. The Police were unable to contact Andrew and a missing persons report was created for Andrew on 17 August 2023. SYP were unable to contact Andrew and contacted both his friend and his brother. On 19th August Andrew’s brother contacted SYP to state he was at a hotel and he was located by Police at a hotel in Sheffield. On 20 August Police were called to a hotel in Sheffield as Andrew was threatening to harm himself. The Police used their s136 Powers to take Andrew to a place of safety for a mental health assessment. SHSC were informed of this by SYP and that he was conveyed to the s136 at Rotherham, Swallownest Court as the s136 in Sheffield was full. SYP handed over Andrew to Swallownest court and provided details to them. It is clear for the documentation form that next of kin details were not provided. Andrew’s brother was informed he was at the s136 suite but then despite him being concerned for his bother received no further updates from SYP and was not informed to contact the s136 suite directly. He was under the impression that SYP would keep him updated. SHSC tried to contact Swallownest Court for any update on the assessment and outcome but did not receive any. I was told they continued to be concerned for Andrew’s welfare. A mental health act assessment was undertaken that determined he did not require any medical recommendation, there was no evidence of mental illness that required admission or referral to secondary services. No next of kin information was available to them and so no information or communication was made with them either during or following the assessment. The outcome of the assessment was not communicated to SHSC or SYP. Andrew was provided with a taxi to take him to Sheffield Train Station as he stated he was going to stay with his brother. At Sheffield Train Station he presented himself to the station manager requesting his laptop be given to the Police and stating that he was being followed by a gang from Germany. BTP Officers spoke to Andrew. I was informed that they undertook a PNC check which identified that he was known to mental health services and there was mention of him being suicidal. I was told it did not contain any information that he had recently been a missing person and that he had recently been detained under s136. There was no next of kin details. The BTP Officer emailed the South Yorkshire Police Force Control to check if they had any details about Andrew and he received an email in response which mentioned he believed he was being followed by gangs and had been a missing person a few days previously but this report was now closed. Due to the lack of information they did not contact mental health services for more information or contact next of kin to confirm that Andrew was stating he was making his way to them. They asked him if he felt suicidal and he answered no. I was told they had no reason to believe he was lying and had no reason to hold him therefore they allowed him to get on a train. SHSC continued to try to contact Swallownest court for the outcome of the assessment and Andrew to no avail during this period due to their continuing concerns. Unfortunately on the train Andrew took his own 2 life. He was found by the train conductor when the train was pulling into Tamworth train station and despite being attended to he was pronounced deceased at the scene. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear. (2) There was missing information on the PNC check which meant that Andrew was not flagged as recently being held under s136. The further email from force control also did not mention that he was recently detained under s136. I was told if this had been on the system BTP would have contacted mental health services for more information. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 January 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the Interested Persons. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 3 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 17 November 2025 Marilyn Whittle, HM Assistant Coroner 4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Detective Chief Superintendent
26th December 2025
Dear Assistant Coroner Marilyn Whittle,
Response to Regulation 28 report in respect deceased Andrew DODDS
Thank you for your letter dated 18th November 2025 and the corresponding Regulation 28
report where you raise two matters of concern. South Yorkshire Police seeks all opportunities
to identify opportunities to learn and improve its response to those we serve.
Upon receipt of this regulation 28 preventing future deaths notice I caused a thorough review
around the actions of South Yorkshire Police in relation to the two matters of concern raised
and will provide below a response against each matter below.
Matter 1
Police did not pass over relevant details including next of kin to the S136
suite meaning next of kin could not be contacted. They also did not inform
next of kin to contact the S136 directly and did not provide any further
updates. This happened shortly after a shift change over so whether a full
handover was provided between officers to allow this information to be
given is not clear.
Section 136 Mental Health Act (MHA) is a power provided to a police constable where, if they
believe a person appears to be suffering from mental disorder and is in immediate need of
care or control, and he thinks it necessary to do so in the interests of that person or for the
protection of others, remove that individual and take them to a place of safety.
This power is temporary and ceases to be in place once that individual is transferred to the
care of another at the place of safety, this would usually be to a health practitioner.
Recognising the impact that detaining an individual has on their Human Rights and the fact
that police officers are not trained to assess mental disorders, the process would involve early
engagement with the relevant NHS trust to ascertain the most appropriate way forward to
support the individual who seems to be experiencing a health crisis. Officers are often directed
by the NHS trust to an available secure suite which is allocated to receive individuals detained
under S136 MHA, or where not available, to an alternative health provision such as A&E.
Upon arrival at the relevant suite officers undertake a formal, documented and approved
handover process with the NHS provider. This will include providing any details we may have
been able to obtain from the individual in relation to their identity, along with the circumstances
of the detention. It needs to be noted that, as the individual is detained at point of crisis it is
not always possible to obtain full details of those detained. The Police would not as a matter
OFFICIAL
South Yorkshire Police Headquarters
Carbrook House
Carbrook Hall Road
Sheffield
S9 2EH
Detective Chief Superintendent
of course seek to identify next of kin details. It is often the case that individuals detained under
S136 MHA are known to the NHS trust who would hold a medical and family history.
Once this handover has been completed the police role ceases completely and the NHS trust
assume responsibility for the individual, along with any relevant updates to next of kin if
assessed as appropriate and in line with Data Protection legislative requirements. This is in
line with the protocols in place between South Yorkshire Police and the Integrated Care
Boards.
It is rare that the police would seek to identify and engage with next of kin in relation to
detaining an individual in a mental health crisis, indeed, as stated above, often the police would
not have access to this information. There could be exceptions to this such as if that individual
is a child, or if the next of kin is present with the person in crisis upon police arrival and
therefore are spoken to as part of our resolution to the incident.
Data Protection legislation would preclude us from contacting the next of kin to share
information about an adult without their expressed consent, this would include the fact that
they have been detained under S136 MHA or taken to a medical establishment. This would
be classed as health data and therefore falls within the stronger legal protections of the Data
Protection legislation.
When considering the specific circumstances, and South Yorkshire Police interactions leading
to the tragic death of Andrew Dodds I have considered the following information and timeline.
17th August 2023
o SYP are contacted by Sheffield Mental Health Trust (Sheffield Health and
Social Care NHS foundation (SHSC)). Mental Health Nurse Connor Crossland
raising concerns for the welfare of Andrew Dodds. He has failed to attend a
crisis appointment and has not returned to his friend’s house where he was
staying. Upon engaging with friend of Mr Dodds, SYP record Mr Dodds as
missing and commence a missing from home investigation.
18th August 2023
o SYP identify details of Mr Dodds’ brother and ascertain he has been in contact
via email with Mr Dodds therefore providing an alternative means of contact.
19th August 2023 at 10:00hrs
o Mr Dodds has responded to an email from SYP and identified that he is staying
in a local hotel. An officer attends the hotel to check on Mr Dodds’ welfare. The
Missing from Home record is then closed.
19th August 2023 at 23:35hrs
o SYP receive a call from a hotel raising concerns for one of its residents (Mr
Dodds) who seems to be in mental health crisis. SYP attend to escalating
behaviour reported by the hotel involving Mr Dodds with a knife threatening to
harm himself if he does not receive any help. Mr Dodds is subsequently
detained by officers un S136 MHA.
o Officers consult via phone with SHSC, speaking with the on call AMHP who
direct officers to take Mr Dodds to Sheffield S136 suite.
o Upon arrival at the suite officers are directed by the mental health team that
they cannot take Mr Dodds into their care as they are unable to deal with his
alcohol withdrawal. Officers are directed to A&E.
OFFICIAL
South Yorkshire Police Headquarters
Carbrook House
Carbrook Hall Road
Sheffield
S9 2EH
Detective Chief Superintendent
o Officers attend A&E and obtain relevant medication for Mr Dodds and re-
engage with SHSC who advise that there is no longer a bed available at the
Sheffield S136 suite but that they have arranged for him to attend Swallownest
Court S136 suite in Rotherham which falls under another NHS trust,
Rotherham, Doncaster and South Humber NHS foundation Trust (RDaSH).
o Officers attend Swallownest Court suite as directed and complete the formal
handover process with the medical staff. At this point the involvement of SYP
in this case ceases and the responsibility of Mr Dodds and his care is assumed
by NHS.
Mr Dodds was detained under S136 MHA due to concerns raised for his behaviour by a third
party, no persons known to Mr Dodds were present. South Yorkshire Police attended and
managed the immediate risk by detaining Mr Dodds under S136 MHA for his own immediate
safety.
In line with our protocols, the officers engaged with SHSC who advised on the course of action
to take which culminated in SHSC directing SYP to take Mr Dodds to the RDASH S136 suite,
Swallownest court as they had no available suitable beds within their health estate.
At the point of handing over the care of Mr Dodds to RDaSH NHS staff, officers would not
have had access to any next of kin details for Mr Dodds. However, even where this information
was immediately accessible to officers the Data Protection legislation would have precluded
SYP contacting Mr Dodds’ next of kin without the clear and expressed permission from Mr
Dodds as this would have led to the sharing of Mr Dodds’ personal health data.
Through the ongoing assessment and treatment of Mr Dodds any engagement or disclosures
to next of kin would be the responsibility of the NHS trust responsible for the individual, in line
with Mr Dodds’ wishes or requirements.
Having reviewed our actions, we complied with Data Protection legislation and therefore we
do not propose any further action in relation to this matter.
Matter 2
There was missing information on the PNC check which meant that Andrew
was not flagged as recently being held under S136. The further email from
force control also did not mention that he was recently detained under s136.
I was told if this had been on the system BTP would have contacted mental
health services for more information.
The Police National Computer (PNC) is a national system used by all Police Services and
other UK law enforcement organisations to access real-time information which has been
gathered and used for law enforcement, policing and safeguarding purposes. The PNC is used
to carry out live time checks in relation to individuals and vehicles.
When someone is convicted of an offence, they will have a substantive PNC record which
documents their criminal history. In addition to this, within this system there are a number of
flags that can be applied against an individual that either relate to their risk, or their risk to
others. These ‘flags’ are nationally agreed flags which all police forces use and as such are
not locally agreed.
OFFICIAL
South Yorkshire Police Headquarters
Carbrook House
Carbrook Hall Road
Sheffield
S9 2EH
Detective Chief Superintendent
There are two different types of flags within the PNC system which are placed against an
individual:
Long term flag such as that the individual is ‘violent’, ‘escaper’ or ‘self-harm’ which
relate to previously witnessed risk that the individual presents to others or themselves
to support officer decision making. These are only in place where there is a substantive
PNC record.
Time limited flags that deal with a live situation and that will be weeded off PNC when
the situation has been resolved. Examples of these being ‘wanted’ or ‘missing’. Once
the individuals are located PNC is updated and these flags are removed.
Where someone does not have a substantive PNC record a temporary record with more
limited details can be created to ‘hang’ the flags against. This temporary record will only remain
for the period of that the flag is relevant for, after this point the record will be weeded and the
individual will again be ‘no trace’ on PNC.
As articulated above, S136 MHA is a temporary power that an officer uses based upon an
individual’s presentation at that time. It provides a power to detain an individual if he thinks it
necessary to do so in the interests of that person or for the protection of other persons and
remove them to a place of safety. This is a short-term power that ceases once the individual
is in a place of safety, this is usually with a mental health professional who is then able to
make an informed assessment about the individual’s health needs. At this point all decisions
and information in relation to that person’s care would be recorded within health systems in
line with the assessment made.
The use of PNC is governed by a clear code of practice - Code of Practice for the Police
National Computer (PNC) and the Law Enforcement Data Service (LEDS) (accessible) -
GOV.UK):
Data stored on PNC should only be created or entered for law enforcement, other policing or
safeguarding purposes. In line with the Data Protection principles, data records should be
adequate, relevant and limited to what is necessary for the specific purpose for which they are
being processed. They must comply with the data protection principles and national data
quality standards.
The use of a S136 MHA flag would not satisfy the codes of practice for PNC. The use of a flag
would only become ‘relevant’ upon a Police Constable making that individual assessment to
detain the person in question under S136 MHA and would cease to be ‘relevant’ once the
individual was in a place of safety. The ‘necessity’ test would therefore not be met as the
individual is already detained by a Police Constable at this point. Further, for most the
population with no criminal history, there would be no substantive PNC account to ‘hang’ this
flag from.
On 20th August 2023, South Yorkshire Police had cause to use their Section 136 MHA powers
detaining Mr Dodds and under the instruction of The Sheffield Mental Health NHS Trust
(SHSC), transported Mr Dodds to a place of safety at which point the Police power and
involvement ceased.
It is worth noting that, at the time Mr Dodds was reported missing, he did not have a
substantive PNC record and as such a temporary record was created as a Missing Report to
ensure this information was available to law enforcement agencies across the country to assist
OFFICIAL
South Yorkshire Police Headquarters
Carbrook House
Carbrook Hall Road
Sheffield
S9 2EH
Detective Chief Superintendent
in safety locating Mr Dodds. Once Mr Dodds had been found, this was updated with a ‘located’
report and this missing instance was weeded off the PNC system a short time later in line with
national protocols.
At the time that Mr Dodds was spoken to by BTP officers, this MFH report was still live on PNC
as it takes a few days for the automatic weeding to be completed. This record clearly shows
that Mr Dodds had been missing, the brief circumstances outlining the missing report including
the note of a ‘suicidal’ marker. In addition to this, there was then the update to state he had
been located and the circumstance of him being located.
Whilst we would always seek any opportunity to learn lessons and make changes to systems
and processes to mitigate future risks, unfortunately South Yorkshire Police is unable to make
changes to the Police National Computer that would satisfy this point. Further, the flagging of
S136 MHA would not be in line with the Code of Practice for PNC, it is a temporary policing
power that can only be used in the moment based on the officers assessment of the individual
at that time, usually at point of crisis to take them to a place of safety where they can be
supported and assessed by trained professionals.
As a result of this recommendation not being compatible with the Codes of Practice we do not
propose any further action on this matter.
Yours faithfully
Detective Chief Superintendent
Head of Crime
South Yorkshire Police
OFFICIAL
South Yorkshire Police Headquarters
Carbrook House
Carbrook Hall Road
Sheffield
S9 2EH
E-mail: laura.koscikiewicz@southyorkshire.police.uk
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