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Human error linked to Kutai's death

Metro released three medical records Friday suggesting that the January death of Kutai, a 20-year-old male Sumatran orangutan, was the result of human error during a minor surgery.

The regional elected government announced that Oregon Zoo Director Kim Smith and Chief Veterinarian Mitch Finnegan had left the zoo last week. Although no details were offered at the time, on Thursday Metro released a statement saying the departures were related to Kutai's death.

According to the statement, the investigation into Kutai's death revealed procedural and communication lapses related to the death, including possible inaccuracies in reports about it.

The newly-released documents include a veterinarian summary report, necrology report, and pathology report written after Kutai's death.

The veterinarian summary report , written by Finnegan, reveals that those involved in the surgery failed to fully monitor a re-breathing bag used on Kutai while he was under anesthesia. At some point the bag became full of expelled air, potentially preventing Kutai from breathing.

A technician assisting in the surgery manually opened a "pop-off" valve when notified the bag was full, but could not say how long it had been full or if Kutai had stopped breathing.

The incident with the bag is included in Finnegan's report, but it also says other factors, including pre-existing medical conditions, could have contributed to the death.

The report says all pop-off valves will be replaced with ones that automatically open when the bags become dangerously full, however. And it said changes were discussed to reduce the amount of multi-tasking required of those monitoring the anesthesia equipment.

Both the necrology report and pathology report suggest problems associated with the anesthetic procedure likely led to Kutai's death.

No mention of the anesthetic procedure problem was included in the press release when the zoo announced Kutai's death. Instead, it included a quote from Finnegan which said, “It’s a devastating loss for everyone here. Our animal-care staff did all we could for Kutai, but we just couldn’t help him through this.”