Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0260, written 16 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2013 |
|---|---|
| Reference | 2013-0260 |
| Deceased | John James Jackson |
| Coroner | Robin Balmain |
| Coroner area | Black Country |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Inquest touching the death of James Jackson (Deceased)
Response to Regulation 28 Report to Prevent Future Deaths
This is the Response of Tomkinson Heating Limited to the Regulation 28 Report to Prevent
Future Deaths issued by Nigel Sharman, HM Senior Coroner for the area of Manchester at
the Inquest touching the death of James Jackson (Deceased) dated 27 November 2014.
The matters of concern raised by HM Coroner were as follows:-
. Report
There was no system for the creation of a bespoke written method statement which is
properly planned, appropriately supervised and carried out in a safe manner for the
movement of the boilers (or any other heavy products, plant or equipment), removal of
any pallet or other packaging etc or the use of other tools or equipment.
Response
Following the tragic incident involving James Jackson, Tomkinson Heating Limited
introduced the attached method statement in respect of using a pallet truck to manoeuvre
boilers and other heavy items entitled “Use of Blue pallet truck” (“THL1”).
We have never undertaken unusual or difficult lifting operations ourselves and on such
occasions always use specialist independent contractors. For example, we always ensure
that when boilers are delivered to a site, the boiler is delivered by the supplier on a vehicle
fitted with a HIAB crane so that it can be safely lifted off the vehicle down to ground level.
We only ever accept delivery of a boiler once it is at ground level and can be manoeuvred
safely by us using a pallet truck.
We have never had an issue with manoeuvring boilers or other heavy items on flat surfaces
using a pallet truck. Operating a pallet truck on a flat surface is not difficult and | would
always explain how jobs were to be carried out in my pre-work briefings with operatives. |
had such a briefing with James Jackson and an in relation to the Sacred Heart
Church job on 11 February 2013 however both James and [were experienced in using
pallet trucks.
Following the incident, the HSE undertook destructive testing of the paliet truck and we
therefore purchased a new so called “blue” pallet truck capable of lifting weights up to
2500kg. | created the method statement for the new pallet truck entitled “Use of Blue pallet
truck” dated 3 November 2013 and circulated this amongst our operatives. The method
statement clearly explains the steps which are to be taken when operating the pallet truck on
flat surfaces and is suitable and sufficient for the majority of jobs that we do.
We have always undertaken specific risk assessments and communicated job specific
methods of work to operatives. In respect of the Sacred Heart Church job, | attach the
written risk assessment entitled “D117 Biomass Risk Assessment” dated 16 March 2012
which specifically states in respect of HDG Biomass Boilers: “Use of purpose made lifting
jacks to remove pallet” (< iad contents of the risk assessment were communicated
to James Jackson and uring the briefing on 11 February 2013 albeit they
would already have been familiar with the risk assessment and method of always using the
lifting jacks having both previously installed this particular type of boiler.
Following the Inquest, however, our procedures have become even more robust. We
produce individual method statements documents (where appropriate) and | attach two
examples entitled “Speedrite - Method Statement” (“THL3”) and “Method statement moving
boiler — Contract Steve Sheldon” (“THL4”),
The Steve Sheldon method statement is dated 23 December 2014 and concerned a job
involving access issues. The boiler was due to be installed in premises at the end of a
narrow lane which the supplier's vehicle was unable to access. The lane surface was not
conducive to using a pallet truck and therefore we hired a front loader. The method
statement for this particular job includes relevant information such as:-
a. Weight and dimensions for the boiler;
b. Issues regarding the weight distribution of the boiler;
c. Use of a front loader to transport the boiler from the point of delivery to the
plant room;
d. Identity of the operatives due to undertake the installation; and
e. Accessibility issues, i.e. the front loader could not be used to place the boiler
in its final position.
The method statement also contains the manufacturer’s instructions which provide specific
information in terms of how the boiler should be positioned and unloaded from its pallet. In
order to remove the pallet, the manufacturer's instructions were followed.
| met Sandra Tomlinson of the HSE on 28 January 2015 and discussed the Inquest as well
as the changes we had implemented. | showed the Speedrite and Steve
Sheldon method statements and recall that she approved them both and made no additional
recommendations or comments. The HSE have not taken any enforcement action.
. Report
There was no apparent system for reporting damage to the lifting jacks (and any other
equipment or tools) and any procedure for a subsequent review of condition and
replacement or repair.
Response
The lifting jacks were not damaged or defective either before or as a result of the incident.
However, steps have been taken by the company since.
At the time of the incident, we had a policy for reporting damage to tools and equipment
which encompassed lifting jacks entitled “P31 - Maintenance and Calibration of Tools and
Equipment Procedure” dated 1 April 2011 a copy of which is attached (“THL5”). We have
never had a problem with operatives failing to report damaged lifting jacks, tools or
equipment. Operatives would report any damaged items to their line manager or myself and
either a replacement would be issued or the damages item would be repaired. This was
however an undocumented system.
Following the Coroner's Regulation 28 Report, we produced the attached form which
operatives now use to report any damaged items entitled “Equipment Damage Report”
(“THL6”). The form includes the following headings:-
i. Equipment
ii. Fault/damage
iii. Action taken
iv. Date resolved
The “Equipment Damage Form’ was sent out to all operatives via the attached e-mail on 15
January 2015 (“THL7”) which included the following instruction:-
“This is our form for reporting any damage or repairs to company equipment. From
this day forward please inspect your equipment and hand this form in with your time
sheets, along with the equipment to be repaired if applicable. Please also use this
form to report any equipment that has been damaged that you have subsequently
repaired, so that we have an audit trail.”
Although there was a system in place for reporting damaged tools and equipment at the time
of the incident, as a result of the Coroner’s Regulation 28 Report we have improved those
procedures and ensured that all operatives are aware of precisely how to report any
damaged tools and equipment.
If we can be of any further assistance to the Coroner then please do not hesitate to contact
us. 7 )
Signed a! ntl
Managing Director of Tomkinson Heating Limited
Dated 3/2 &, {1S
Smethwick Council House
High Street
Smethwick
West Midlands
B66 3NT
Robin J. Balmain
H.M. CORONER
‘ _ Tel: 0845 352 7483
BLACK COUNTRY CORONER'S DISTRICT Miah sega
(SANDWELL ¢ DUDLEY * WALSALL - WOLVERHAMPTON E-mail:
Metropolitan Borough Councils) barbara_powles @sandwell.gov.uk
elaine_huckfield@sandwell.gov.uk
Date: 16 October 2013 Our Ref: RJB/BAP Your Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Secretary of State
Department of Health
Richmond House
79 Whitehall
London SW1A 2NL
1. CORONER
I Robin John Balmain am the Senior Coroner for the Black Country Coroners
Jurisdiction
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 2-4 May 2013 I commenced an investigation into the death of JOHN JAMES
JACKSON. The investigation concluded at the end of the inquest on 10 October
2013. The conclusion of the inquest was that death was due to an accident.
4. CIRCUMSTANCES OF THE DEATH
This man was found dead at his home. Life was pronounced extinct at 12 noon on 24
May 2013.
Ds CORONERS CONCERNS
I heard and accepted evidence that the deceased was a compulsive user of a product
called “Hero Energy Mints”. This produce is advertised as having “More than all the
normal advantages of energy drinks in an easy to use format”. The advertising says
that one mint equals one whole energy drink. It went onto say that the product
This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm
H.M. SENIOR CORONER
16 October 2013 Continuation
a
contains caffeine. However, the information available on the internet at the time of
the inquest contained no information at all as to the dangers of consuming large
quantities of the mints. At the inquest, the evidence from the pathologist showed
that Mr. Jackson had in his blood at the time of death, more than twice the level of
caffeine that can produce a fatality and around 50 times the level that would be found
normally in someone drinking tea and coffee.
The MATTERS OF CONCERN are as follows :-
a) There was at the time little information available as to the level of caffeine in
this product and the dangers of consuming large amounts of caffeine,
b) The product seems to me to sit uncomfortably in a gap between medication
and sweets, hence any person treating the product simply as sweets maybe in
danger. I acknowledge of course, that part of the answer is public awareness
and I trust that the publicity that was given to this case may assist in that
regard.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of the
report, namely by 11% December 2013.
COPIES and PUBLICATIONS
I have sent a copy of my report to the Chief Coroner and to the following interested
Persons :
) Eo
(b) Hero Energy Ltd
I am also under a duty to send the Chief Coroner a copy of your response.
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
H.M. SENIOR CORONER
16 October 2013 Continuation
your response, about the release or the publication of your response by the Chief
Coroner.
R.J. Balmain
H.M. Senior Coroner
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