Concerns raised 8 Failure to seize and retain relevant scene samples and evidence for later investigation View source Failure to immediately store or freeze stomach contents for triggering-allergen analysis View source Lack of a standard protocol ensuring appropriate samples are taken at the correct time View source Failure to collect and store an early post-mortem blood sample for later analysis View source Failure to retain hospital blood samples for testing View source Failure to raise possible anaphylaxis deaths with the senior coroner at the earliest opportunity View source Failure to collect blood samples for mast cell tryptase and specific IgE serology in suspected anaphylaxis View source Failure to collect and retain tissue samples in suspected anaphylaxis View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benedict BLYTHE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to seize and retain relevant scene samples and evidence for later investigation
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately store or freeze stomach contents for triggering-allergen analysis
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard protocol ensuring appropriate samples are taken at the correct time
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and store an early post-mortem blood sample for later analysis
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to retain hospital blood samples for testing
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to raise possible anaphylaxis deaths with the senior coroner at the earliest opportunity
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to collect blood samples for mast cell tryptase and specific IgE serology in suspected anaphylaxis
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and retain tissue samples in suspected anaphylaxis
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained .
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Open source report
×
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 Include revised child-death investigation processes in ongoing training cycles for frontline and investigative staff.
Verbatim wording from the response “Finally, the revised processes are now included within ongoing training cycles for child death investigations, meaning all staff involved in frontline or investigative roles will receive regular reinforcement of expectations and good practice standards. This training emphasises the forensic, investigative, and safeguarding considerations required in early decision-making, helping ensure that opportunities to understand cause of death are preserved and that future investigations are informed by best practice.” Source location Response form Cambridgeshire Constabulary
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 Amend, reissue and widely circulate procedural guidance and aide-memoires for child-death investigations, covering evidence preservation, medical liaison and anaphylaxis considerations.
Verbatim wording from the response “Second, the Constabulary has amended and re-issued internal procedural guidance and aide-memoire materials relating to child death investigations. These documents have been circulated widely to all officers and staff who may attend such incidents,” Source location Response form Cambridgeshire Constabulary
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 Establish SOCO liaison and incorporate assessment and seizure of potentially evidential biological samples into child-death forensic strategies.
Verbatim wording from the response “First, full liaison with Scenes of Crime Officers (SOCOs) has been established to ensure that, in all cases of unexplained child death, the potential evidential value of samples found at the scene—such as vomitus or other biological material—is actively recognised and considered. SOCOs have been formally briefed, and the need to assess and seize such samples is now incorporated into the forensic strategy in consultation with the Senior Investigating Officer. This ensures that opportunities to preserve material for the Coroner, the Pathologist, or investigators are not missed.” Source location Response form Cambridgeshire Constabulary
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
Concerns raised 10 Inadequate tiger-enclosure entry method statement and risk assessment View source Insufficiently clear and prescriptive guidance on double gates for tiger enclosures View source Over-reliance on individual keeper reliability as the tiger-enclosure entry control View source Lack of clear guidance requiring licensed conventional firearms at zoos holding tigers View source Absence of double keeper gates to tiger paddocks View source Inadequate fatigue-risk controls for keepers undertaking night-time hand-rearing View source Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems View source Insufficient trained firearms staff to provide continuous zoo cover View source Failure to complete approval, secure storage and acquisition of conventional firearms View source Lack of access to conventional firearms for escaped or uncontrolled tigers View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
ROSA ANN KING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rosa Ann King, a senior carnivore keeper at Hamerton Zoological Park, died on 29 May 2017 after being attacked by a Malayan tiger while exiting the tiger paddock. She had entered while the tiger slides were open, and the report identified concerns about reliance on keeper reliability, fatigue from night-time hand-rearing work, the absence of air-lock type double gates, and lack of access to conventional firearms. The report also raised concerns about insufficient guidance, risk assessment and inspection of these safety arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate tiger-enclosure entry method statement and risk assessment
Wider context from the report “5.4.2 I heard evidence that Hamerton zoo’s “Review of Tiger Protocols” was not a suitable method statement for working in the tiger enclosures . It did not explicitly set out every necessary stage of checks in the system for entering a tiger area ; it had not been updated; it addressed only some of the tasks that were required (for example, it did not address entry into the Tiger paddock where Rosa was attacked). I heard evidence that the relevant risk assessment was not suitable ; that it did not consider the risk of human failure , and did not address the risk of a member of staff omitting a critical check or action due to an unintentional slip, lapse or mistake, or an intentional violation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear and prescriptive guidance on double gates for tiger enclosures
Wider context from the report “5.2.6 I am concerned that:
• Hamerton Zoo was able to pass previous ZLA inspections without any recommendation being made that a double keeper gate be fitted to its tiger enclosures.
• The DEFRA guidance by inclusion of the words, “In general …” is insufficiently clear and insufficiently prescriptive on the standards that should apply to an enclosure holding animals as deadly as tigers. Similar considerations apply to the HSE guidance.
The fact that other zoos may not have double keeper gates fitted to tiger enclosures, and the lack of more prescriptive guidance , carry a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on individual keeper reliability as the tiger-enclosure entry control
Wider context from the report “5.4.1 The system for entering the tiger enclosures at Hamerton zoo was simple, and involved a number of visual checks by the tiger keeper. However, as found by the jury, I heard evidence that this system was totally dependent on the keepers reliably following their training . There was no further control measure (whether involving engineering design, a flag or sign system, CCTV, the use of radio checks or otherwise) to limit the human error risk. I heard expert evidence that training on its own is not an effective measure to reduce the risks of slips, lapses or violations. I heard evidence that in relation to a task which carries the risk of single or multiple fatalities, human actions should not be relied on to be the control of the hazard unless as a final resort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance requiring licensed conventional firearms at zoos holding tigers
Wider context from the report “5.1.4 I heard evidence that DEFRA’s “Secretary of State’s Standards of Modern Zoo Practice” is being redrafted/has been redrafted but is not yet published. Paragraph 8.20 of the guidance as currently drafted states,
“Where a zoo holds any primate, carnivore, elephant, or hoofed mammal listed in category 1 of Appendix 12, appropriate firearms must be available, unless a risk assessment has shown that a firearm would not provide the most appropriate means of protection to the public from that animal, and other arrangements have been made.”
I am concerned that the wording of this provision may have contributed to the zoo being able to pass ZLA inspections since it held one form of firearm (a dart gun) and had an arrangement with local police for conventional firearms cover. In contrast, I received evidence from an independent expert and highly experienced zoo manager, designer and consultant that he was “stunned to learn that no firearms were kept on site at Hamerton and they had had tigers since around 2003”. I am concerned that a lack of clear guidance that all zoos which hold tigers must possess licensed conventional firearms carries a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of double keeper gates to tiger paddocks
Wider context from the report “5.2.1 I am concerned that, some time, error on the part of a safety-conscious experienced zoo keeper led to a situation whereby a tiger could have attacked multiple members of the visiting public. Double keeper gates to the tiger paddock would very likely have prevented this risk. They were not fitted at the time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate fatigue-risk controls for keepers undertaking night-time hand-rearing
Wider context from the report “5.3.2 I heard evidence that since Rosa’s death, the zoo has introduced a formal policy for the hand-rearing of animals. That policy (which on its face was meant to have been reviewed on 24 April 2019) reduces, but does not eliminate, my concerns in this regard. It provides that the period of consecutive days staff spent hand-rearing should be “kept to a minimum”. However, it goes on to provide that this is to be, “at the staff members own discretion” after what is said to be “self-evaluation” . For hand-rearing done at home, the work remains viewed as voluntary and unpaid. The policy does not make provision for the hours spent in such activity to be monitored for safety reasons , although in a document provided on the last day of the inquest, I was told that this would be introduced before any further hand-rearing was done. The policy does not make any separate provision or safeguards for those keepers whose day jobs involve them working with the highest risk animals like tigers , where there is a risk of fatalities if fatigue-induced mistakes are made. No advice had been taken from any outside expert on the safety implications of night-working or the patterns of work being undertaken . I am concerned that there remains a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems
Wider context from the report “5.4.6 In light of the aforesaid, I am concerned that there is an ongoing risk nationally that systems for entering tiger enclosures may be entirely dependent or overly-dependent on the reliability of individual zoo keepers without sufficient account being taken of the risk of human failures . Further, such risks may not be effectively addressed by zoo inspections nor sufficiently publicised in DEFRA and HSE guidance . This carries a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient trained firearms staff to provide continuous zoo cover
Wider context from the report “5.1.3. Moreover, at present only two members of the zoo staff have been trained to use conventional firearms . I am concerned that this is too few a number to ensure that a member of staff trained in conventional firearms will always be on duty when the public have admittance to the zoo . This carries a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete approval, secure storage and acquisition of conventional firearms
Wider context from the report “5.1.2 I heard evidence that the zoo has taken measures for two members of staff to obtain firearms’ licences and they have received firearms training. However, I heard evidence that the zoo has not yet been approved as premises to hold firearms (action for which rests with the firearms licensing department at the local constabulary) and the zoo has not yet fitted appropriate firearm secure containers . While moving to hold conventional firearms has been made a condition of the zoo’s licence under the Zoo Licensing Act 1981 (ZLA), I am concerned that more than two years after Rosa’s death, the process of the zoo obtaining conventional firearms has still not been completed . This carries a risk of further deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of access to conventional firearms for escaped or uncontrolled tigers
Wider context from the report “5.1.1. Should a tiger escape from the tiger enclosures at Hamerton Zoo or a keeper should inadvertently find themselves in the same area as a tiger, I am concerned that the zoo still does not currently have access to conventional firearms to shoot a tiger in that situation to preserve human life .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations