On the fifth day of the hearing, the jury at Huntingdon Town Hall heard from zoological consultant Douglas Richardson who compiled two reports in which he raised concerns about safety, describing the system at Hamerton as "dangerously random". Rosa died on May 29, 2017, in the zoo's tiger paddock after she was attacked by a male Malayan tiger called Cicip. Mr Richardson, who has worked in the industry for 40 years, including a stint at London Zoo, visited Hamerton in April 2018 and published his first report in May of that year. He was asked by coroner Nicholas Moss about the vertical slides which are used to isolate tigers from staff and whether the zoo had followed guidance laid down by Defra. "There are variations across the industry, but in my view the guidelines on double gate systems say they 'should be' in place rather than 'must be' and I believe this is an error in the recommendations." Mr Moss said: "So you would have recommended an air-locked double gate system at the Malayan tiger enclosure," and Mr Richardson replied: "Absolutely, yes." Mr Moss also asked him to comment on his concerns that a tiger may be able to lift up the vertical slide gates, which are operated by a system of metal wires and pulleys. "I have seen it happen on a number of occasions at other zoos," he said. Mr Richardson went on to describe the zoo's tiger protocol as a "relatively simple document" that was "not particularly thorough". Mr Richardson also pointed out that the document pre-dated the opening of the new enclosure for the Malayan tigers and had not been updated. During cross examination from Dominic Kay, representing Hamerton, Mr Richardson did concede that a lack of double door system would not have affected the outcome on the day of Rosa's death. Later in the day, the inquest heard from Susan Walford, operations manager at Huntingdonshire District Council. The authority is responsible for making health and safety checks at the zoo. The inquest heard documents for an inspection in 2014 were not available and an inspection in 2016 had been missed altogether. Ms Walford, who joined HDC on May 1, 2017 studied the previous reports and said in her view some of the zoo's protocols for keepers did not contain enough detail and she would have expected inspectors to have picked this up. She did point out, however, that not all documents were examined on every visit. Asked if she would have raised a concern about the tiger protocol, she said: "Yes I would." "It hadn't been updated after the arrival of the Malayan tigers and not all of the tasks that were carried out by keepers were in the document. This should have been picked up," she said. Miss Walford was asked about the council's failure to inspect in 2016 and whether this could have impacted on the outcome of the events on May 29, 2017. She replied: "It was a missed opportunity to change things, but whether it would have prevented the accident occurring, I don't know." The inquest continues.