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The lung hemorrhage that killed Oregon Zoo orangutan Kutai in January was likely caused by a failure to monitor his anesthesia during surgery, according to veterinary reports released this morning by Metro.
Regional planning agency Metro fired zoo director Kim Smith and chief veterinarian Mitch Finnegan on Monday. Officials announced Thursday that the firings were a direct result of Kutai's death.
The zoo released three medical records related to the orangutan's death this morning—his necrology report, pathology report and vet summary report—in response to an information request filed by WW under Oregon public records law.
The records say that Kutai died January 4 after a minor surgery two days earlier to treat an infection in the air sacs along his neck.
The veterinary report, written by Finnegan, says that during the surgery, technicians failed to monitor the valve on the animal's anesthesia bag that controls the re-breathing circuits and allows waste gasses to be vented.
"During radiographs [a volunteer named Barbara] noted that the re-breathing bag on the anesthesia circuit was very full," Finnegan writes.
Technician Kelli Harvison "reacted by immediately opening the 'pop-off' valve on the anesthesia machine which released any pressure in the circuit," Finnegan writes. "At this time I asked her how long the valve had been closed for and how high the pressure got to. She answered that she did not know to both questions."
In his assessment of Kutai's death, Finnegan wrote that the zoo didn't use the most up-to-date anesthesia valves, which would automatically release pressure, and technicians assigned to anesthesia often performed other tasks.
Interim zoo director Teri Dresler wrote to zoo employees and Metro councilors this morning, saying she had no choice but to release the medical reports, because media made records requests and Finnegan talked about his firing to The Oregonian.
"We lose this capacity to keep information confidential," Dresler wrote, "when an employee impacted by the personnel action speaks to the news media and also when news media files a public records request and under law we are obligated to disclose the records."
The firing of Smith and Finnegan has drawn national attention.
Zoo evaluator Kathayoon Khalil wrote an elegy for Kutai on Slate this morning, in which she defends zookeepers' efforts to care for animals in captivity.
Khalil quotes former Oregon Zoo director Tony Vecchio, who says the old primate exhibit was the zoo's worst during him time there—and made more difficult by Kutai's intelligence.
"Kutai was not an animal you wanted to play chess with," Vecchio tells Slate, "he was always thinking three moves ahead."
UPDATE, 12:10 pm: Anonymous Oregon Zoo sources who attended an all-staff meeting Thursday tell The Oregonian that Metro officials said the firings were based on a lack of honesty about Kutai's death.
That corresponds to the zoo's Thursday announcement, which blamed the firings on "a lack of trust regarding the accuracy of reports and whether important facts regarding animal care were omitted."
The zoo's initial announcement of Kutai's death said he died after surgery, but didn't mention procedural error.
"Our animal-care staff did all we could for Kutai," Finnegan said in the press release, "but we just couldn't help him through this."
WWeek 2015