PFD report

JOHN JAMES JACKSON · Prevention of Future Deaths report

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Issued 16 Oct 2013•Black Country

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Danger of treating caffeine-containing energy mints as ordinary sweets
    Part of recurring concern: Inadequate product safety warnings about serious hazards
  2. Lack of information on caffeine levels and the dangers of consuming large amounts of caffeine
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Danger of treating caffeine-containing energy mints as ordinary sweets

Wider context from the report

“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 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. 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, when 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. ”

Is this part of a recurring concern?

Yes — Inadequate product safety warnings about serious hazards.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of information on caffeine levels and the dangers of consuming large amounts of caffeine

Wider context from the report

“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 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. 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, when 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Introduce an Equipment Damage Report form and instruct all operatives to use it for damaged or repaired equipment, creating an audit trail.

    Stated by Tomkinson Heating LimitedStated completedThe respondent said that this action was complete when they made their response on 29 January 2014.
  2. 2

    Produce individual method statements for appropriate jobs, including equipment, load, operative, access and manufacturer-instruction details.

    Stated by Tomkinson Heating LimitedStated completedThe respondent said that this action was complete when they made their response on 29 January 2014.
  3. 3

    Purchase and use a new blue pallet truck capable of lifting up to 2,500kg.

    Stated by Tomkinson Heating LimitedStated completedThe respondent said that this action was complete when they made their response on 29 January 2014.
  4. 4

    Create and circulate a method statement explaining safe operation of the blue pallet truck on flat surfaces.

    Stated by Tomkinson Heating LimitedStated completedThe respondent said that this action was complete when they made their response on 29 January 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    A system already existed for reporting damaged tools and equipment, including lifting jacks, despite being undocumented.

    Stated by Tomkinson Heating LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Specialist independent contractors handle unusual or difficult lifting operations, while the pallet-truck method statement is sufficient for most company jobs.

    Stated by Tomkinson Heating LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. 3

    The lifting jacks were neither damaged nor defective before or as a result of the incident.

    Stated by Tomkinson Heating LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce an Equipment Damage Report form and instruct all operatives to use it for damaged or repaired equipment, creating an audit trail.

Verbatim wording from the response

“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:-”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 2 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce individual method statements for appropriate jobs, including equipment, load, operative, access and manufacturer-instruction details.

Verbatim wording from the response

“Following the Inquest, however, our procedures have become even more robust. We produce individual method statements documents (where appropriate) and I attach two examples entitled “Speedrite – Method Statement” (“THL3”) and “Method statement moving boiler – Contract Steve Sheldon” (“THL4”).”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 2 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Purchase and use a new blue pallet truck capable of lifting up to 2,500kg.

Verbatim wording from the response

“Following the incident, the HSE undertook destructive testing of the pallet truck and we therefore purchased a new so called “blue” pallet truck capable of lifting weights up to 2500kg. I 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.”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 1 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Create and circulate a method statement explaining safe operation of the blue pallet truck on flat surfaces.

Verbatim wording from the 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”).”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 1 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A system already existed for reporting damaged tools and equipment, including lifting jacks, despite being undocumented.

Verbatim wording from the response

“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.”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 2 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Specialist independent contractors handle unusual or difficult lifting operations, while the pallet-truck method statement is sufficient for most company jobs.

Verbatim wording from the response

“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.”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 1 · response
Published 29 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The lifting jacks were neither damaged nor defective before or as a result of the incident.

Verbatim wording from the 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.”

Source location

2013-0260-Tomkinson-Heating-Limited
Page 2 · response
Published 29 January 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026