An investigation by the government agency that runs the Oregon Zoo found that zoo leaders didn't report all the human errors around the death of Sumatran orangutan Kutai.

The zoo's deputy director described veterinary actions in Kutai's final hours as "sloppy," the report says—yet zoo leadership didn't ask for an outside investigation or discipline any staff.

A Metro investigator found that zoo medical staff didn't have cardiac drugs or a "crash cart" available when Kutai's heart failed, the battery on the ultrasound machine was dead when veterinarians tried to revive him, and a medical assistant was sending text messages during the ape's final surgery.

The investigation led to the firing this month of zoo director Kim Smith and chief veterinarian Mitch Finnegan.

In the weeks following the firings, zookeepers have protested Finnegan's treatment and demanded he be reinstated. 

Regional planning agency Metro released a summary of the investigation today after WW and The Oregonian sought a legal order requiring the release under Oregon public records law.

Metro had previously released records showing Kutai died after minor surgery Jan. 2, and that one reason for his death was a vet's failure to monitor a "breathing bag" that filled his lungs during anesthesia.

He underwent a second surgery two days later, and died after being returned to his habitat, Red Ape Reserve.

The summary now reveals that as Kutai went into cardiac arrest on Jan. 4, Finnegan "requested the 'crash cart' and cardiac drugs, but [an assistant] had left them at the hospital. ... Ten to twenty minutes later, [the assistant] arrived with the missing equipment and drugs. [Finnegan] then requested the portable ultrasound machine. The ultrasound machine could not be used because the battery was dead."

Smith, the zoo director, was also present at Kutai's death, the report says.

The summary says Finnegan told one curator "that they had killed Kutai." But it says he didn't mention the issues his managers raised with his staff, and didn't discipline any of them.

The report highlights the lack of disciplinary action, and says Finnegan had only disciplined staff "twice in the last seven years."

Metro's summary says that deputy director of living collections Chris Pfefferkorn described the mistakes around Kutai's death as "sloppy"—but both he and Smith recommended no outside review, because they trusted Finnegan.

But the report says an investigation was triggered by an anonymous complaint to a Metro "ethics line" on Feb. 23.