Prevention of Future Deaths reports · 2025

Andrew Dodds

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 report17 Nov 2025
Reference2025-0587
DeceasedAndrew Dodds
CoronerMarilyn Whittle
Coroner areaSouth Yorkshire (West)
CategorySuicide (from 2015) · Mental Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from South Yorkshire Police (PDF)
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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