Source · Prevention of Future Deaths

Andrew Dodds

Ref: 2025-0587 Date: 17 Nov 2025 Coroner: Marilyn Whittle Area: South Yorkshire West Responses identified: 1 / 1 View PDF

Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.

Date 17 Nov 2025
56-day deadline 12 Jan 2026 est.
Responses identified 1 of 1
Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.
View full coroner's concerns
(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.

Responses

1 respondent
South Yorkshire Police Police / Law Enforcement
26 Dec 2025 PDF
Noted

South Yorkshire Police have reviewed the concerns. They state that the s136 power is temporary and they engaged with the NHS trust. They are unable to make changes to the Police National Computer. (AI summary)

View full response
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

Detective Chief Superintendent OFFICIAL South Yorkshire Police Headquarters Carbrook House Carbrook Hall Road Sheffield S9 2EH 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.

Detective Chief Superintendent OFFICIAL South Yorkshire Police Headquarters Carbrook House Carbrook Hall Road Sheffield S9 2EH 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.

Detective Chief Superintendent OFFICIAL South Yorkshire Police Headquarters Carbrook House Carbrook Hall Road Sheffield S9 2EH 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

Detective Chief Superintendent OFFICIAL South Yorkshire Police Headquarters Carbrook House Carbrook Hall Road Sheffield S9 2EH E-mail: laura.koscikiewicz@southyorkshire.police.uk 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.

Report sections

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 .
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 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 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.

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Report details

Reference
2025-0587
Date of report
17 November 2025
Coroner
Marilyn Whittle
Coroner area
South Yorkshire West

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Jan 2026 (estimated).

Sent to

South Yorkshire Police Headquaters

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