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
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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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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 Sphere Risk Health & Safety Management Ltd; 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