Pattern of Mistakes Found in Zoo Deaths
Review Shows Some Veterinary Records Were Changed

Karlyn Barker and James V. Grimaldi
Washington Post Staff Writers
Sunday, December 7, 2003; A01

Neglect, misdiagnosis or other mistakes have marked the deaths of 23 animals at the National Zoo in the past six years, and some veterinary records are incomplete or were changed after the fact, according to documents and interviews with current and former zoo employees.

A review of thousands of pages of zoo reports shows that records were changed or were incomplete in files on eight animal deaths -- including the deaths of an orangutan, a lion and a giraffe.

In three cases -- involving the lion, a bobcat and a rare bird -- notations have been deleted or passages have been added in electronic veterinary records. No official veterinary record was filed after the death of a giraffe during an anesthesia procedure. The zoo said it could not provide keeper notes on the daily care of two rare zebras that died of hypothermia and starvation. Zoo euthanasia forms were not completed for the bobcat, a tree kangaroo and an endangered black-footed ferret.

In two cases -- involving an orangutan and one of the zebras -- the records are at odds with what a curator and a former curator say took place before the animals died.

Donald K. Nichols, a longtime zoo pathologist, alleged that records were "altered" after some deaths and accused the zoo of trying to "cover up" mistakes. He criticized the veterinary care in a recent letter to the National Academy of Sciences, which is investigating animal deaths.

Zoo Director Lucy H. Spelman said in an interview last week that there was no intention to obscure facts about the animal deaths when records were changed. She described the electronic veterinary records as "sort of a living document" and said corrections would have been based on the "veterinarian who's responsible feeling that a correction needs to be made." Spelman, formerly head veterinarian, did not comment on specific changes but said records are meant to provide "our best understanding of what is happening, has happened. It's complicated."

Spelman added, "Everybody here is here to try to make sure the animals are okay."

In the records and interviews, some patterns emerged.

Records show veterinarians did not tend to some sick animals promptly, particularly small mammals, and in some cases keepers and curators said veterinarians did not heed their concerns. Sometimes veterinarians were so focused on one problem that they missed a more serious one. An elephant received months of medical attention for a foot infection but was not given a federally required test that might have shown that it had tuberculosis. Two older giraffes also were treated for lameness, but no one diagnosed the age-related digestive problems that later killed them.

Sometimes, animals died as a result of medical procedures that went awry. A macaque, a type of monkey, was euthanized after urinary tubes were damaged in surgery to remove a tumor. A lion and a giraffe died during and after anesthesia procedures.

Spelman, who did the procedure on the giraffe, did not write up a veterinary record. She later provided The Washington Post with a copy of her notes."When an animal dies, so much is happening at that moment," she said in an interview last week. "That last medical record entry should be done, but obviously, in that case, I didn't get it done."

Animal deaths at the National Zoo have received extensive scrutiny since January, when two red pandas died after eating rat poison buried in their yard. At the request of Congress, the Academy of Sciences has launched its investigation.

Last month, Nichols, who performed postmortem examinations in many of the most controversial cases, provided the academy with packets of veterinary records and a detailed letter criticizing Spelman and Suzan Murray, the current head veterinarian.

"Because of incompetence in management and veterinary medicine, the operations at the National Zoo have been in such a state of disarray that it has led to poor animal care, animal suffering and even animal deaths," Nichols, 45, declared in his 48-page letter.

Nichols, who has given notice of his intention to resign, wrote that he could document mistakes in 21 animal deaths that "clearly establish a pattern of long-standing and on-going incompetence, malfeasance and/or malpractice of veterinary medicine by both Lucy Spelman and Suzan Murray."

"I'm sad that Don feels that way," Spelman said early last week. "And I'm sad that Don would be as critical as he is given that I know he does care about the animals."

Spelman added in a statement Friday: "Dr. Nichols' perspective is based on his interpretation of records he did not create, situations in which he did not participate, and areas in which he had no expertise. As a pathologist, he studied animals after they died, and determined the cause of death."

Murray said that the records "are not designed as a legal document" and that changes reflected the zoo's "user-friendly" approach to information-sharing.

"Although we try to be thorough and complete, it is simply not possible for us to document every conversation and every observation," Murray said in a statement. "Instead an attempt is made to document, update and edit those of the greatest medical importance."

Nichols, an associate pathologist, is lauded on the zoo's Web site for his "pioneering studies" to rid Guam of nonnative brown tree snakes. In announcing his departure, the zoo said he had helped identify a disease considered partly responsible for amphibian decline worldwide.

The Washington Post obtained a copy of Nichols's letter and critique under the Federal Advisory Committee Act.

Spelman, 40, was named zoo director in June 2000, and Murray, 41, was named head veterinarian in April 2001. Spelman is one of two board-certified veterinarians serving as directors of U.S. zoos. Murray, who had previously served a veterinary residency at the National Zoo, came back after working as a veterinarian at the zoo in Fort Worth.

Spelman and Murray deny allegations of poor veterinary care at the world-renowned, 163-acre park. In some instances, they have blamed keepers, who provide day-to-day care, or curators, who supervise care of particular species in the 2,500-animal collection, for not being more attentive to the animals or failing to communicate concerns more forcefully.

Many of the problems with care occurred several years ago, and the zoo has made significant improvements, Spelman said. It intends to make more changes, including updating its record-keeping computer software, she said.

"We're on the right track," Spelman said. "It doesn't mean we've made all the changes we need to make. We're going to keep making the zoo better."

This year, Spelman hired a nutritionist and a pest-control expert, as well as three curators. She also has updated written protocols for euthanizing animals.

Spelman has said she inherited money problems, deteriorating facilities and a dwindling animal collection. A 10-year, $250 million capital improvement plan is moving forward, and efforts are underway to "infuse youth" in the animal collection, she said.

The zoo, which draws 2.8 million visitors a year, is part of the federally funded Smithsonian Institution. In March, the American Zoo and Aquarium Association gave the zoo a one-year, provisional renewal of its accreditation, instead of the usual five-year renewal, citing funding, staffing and facility problems. The U.S. Fish and Wildlife Service recently renewed the zoo's endangered species permit for one year, instead of the usual three, citing concerns about animal deaths.

In an interview with CBS News in March, as a congressional committee was about to hold a hearing on the accidental poisoning of the red pandas and other questionable zoo deaths, Spelman said, "All of the animals that have died, with the exception of the red pandas, which shouldn't have happened, died of either old age or disease."

Six months later, Spelman said in a message Sept. 25 to zoo staff members and donors: "The majority of these animals died because they were aged, ill or injured. In a few instances, animals died because we did not do our job as well as we should have."

Zoo medicine is inherently challenging. Zoo veterinarians deal with exotic and often dangerous animals that cannot be handled easily.

Like other zoos, the National Zoo maintains an array of records about its animals, including veterinary records, written by the staff of the Department of Animal Health, and keeper records, written by the staff that provides day-to-day care.

The zoo keeps its veterinary records in a database. Entries are dated and usually initialed by the people who make them -- veterinarians, students or animal-health technicians, Murray said in an interview. Records are changed after the fact, she said, but only for minor editing corrections.

J. Andrew Teare, an official with the zoo in Jacksonville, Fla., who created medical-record computer software used by the National Zoo and others, recently briefed the Academy of Sciences on the importance of records. In an interview, he said that although there are no standards on what a veterinarian might put in or take out, records should accurately reflect what happened.

"If I make a diagnosis and change my mind, I don't usually go back" and make deletions and additions in the original report, Teare said, noting that substantive changes typically would be identified as an addendum.

Spelman, Murray and several curators and keepers agreed to interviews with The Post. The Post contacted other employees and outside experts in veterinary medicine. In examining the zoo's practices, The Post also obtained keeper notes, veterinary records, euthanasia forms, pathology reports and minutes of meetings of a zoo committee that reviews animal care.

Tana, a 13-year-old lion, died in October 2002 after being anesthetized in preparation for a physical examination to see why he was limping. In interviews, Murray portrayed the death as a puzzling outcome to a routine procedure. Lions in captivity have a life expectancy ranging from the mid-teens to the thirties.

A review of the veterinary records shows that nearly twice as much anesthesia was used as in eight previous medical procedures -- despite a warning in the records from 1995 to decrease dosages after Tana suffered a seizure.

In examining the lion's death, The Post reviewed two versions of veterinary records describing the Oct. 10 procedure.

The earlier version was provided in November to the Academy of Sciences by Nichols and is a copy of computerized notes he printed out 10 days after Tana's death. The later version was included in documents The Post received from the zoo this past summer.

The earlier version of the records says a keeper administered the first sedation shot. In the later version of records, the keeper's role is deleted.

Murray and Spelman recently said they let the keeper make the first injection through the bars of Tana's cage. Spelman said animals often recognize veterinarians and will not let them get close enough to administer a shot. Murray, who was in charge of the procedure, and Spelman, who was assisting her, stayed out of sight, in an office.

The keeper, Mindy Babitz, who had never before given anesthesia to a lion, said in an interview that she thought the animal received the entire first dose.

When Tana didn't go down after 25 minutes, Murray administered more drugs, veterinary records show. The lion was injected or darted four more times because Murray and Spelman were not sure how much anesthesia had been absorbed. "We felt like only 10 percent [of the first dose] went in," Murray said in an interview in the spring.

Some references to problems that occurred while the animal was under anesthesia were deleted or reworded in the later version of records.

One notation in the earlier version says the lion's breathing tube may have been placed too far down the windpipe and was "moved back a little." Another notation in the earlier version says the problem with the breathing tube might explain why the lion's heart rate shot up. Yet another notation says an intravenous catheter dislodged after 10 minutes, requiring fluids to be administered beneath the skin.

The reference to the breathing-tube problem does not appear in the later version of records, nor does any speculation that the tube might have caused an increase in the heart rate. Problems with the IV also are not mentioned.

The later version of records also contains additions. An incident described in the earlier version as a seizure was changed to a "mild" seizure in the later version, which also adds a description of the lion as "stable under anesthesia."

Both versions from Oct. 10 bear the initials of a veterinary student who was under Murray's supervision. She no longer works for the zoo and has declined repeated requests for an interview.

"Why were the medical records altered? Who altered them?" Nichols asked in his letter. "Isn't it obvious that the intent of the alterations . . . was to remove any statements that made it appear that there were any problems with or anything unusual about this anesthetic event?"

Murray did not comment on any changes but said in a statement that notes by students often are edited. "Missing information is added days, weeks and sometimes even years after the original date of entry," the statement said.

The veterinary records for Oct. 11 -- the day Tana was found dead -- are at odds with the recollections of the lion's keepers. An entry with Murray's initials said, "Recovery yesterday was uneventful," and, "Keepers reported he was up and walking, but later went back to sleep."

According to interviews with keepers Babitz and Tracey Barnes, veterinarians were called twice because of concerns that Tana was not recovering from anesthesia and was "woozy."

Babitz and Barnes said Murray told the lead lion keeper in a phone call Oct. 10 that the slow recovery was normal given the amount of anesthesia. Barnes said she left a voice-mail message at the animal hospital at the end of the day reporting that the lion's condition had not changed.

No veterinarians came.

The postmortem report, written by Chief Pathologist Richard J. Montali, said Tana was last seen alive by a keeper at 6:30 p.m. Oct. 10, still "glassy-eyed" and "dopey." Tana, left alone for 12 hours, was found dead the next morning of complications of anesthesia, the pathology report said.

In a recent interview, Murray said the keepers told her that the recovery was proceeding normally: "For me, all indications were the lion is doing fine."

Murray suggested that the lion might have died of an unknown illness such as a neurological condition.

The zoo now requires veterinarians to check on animals after anesthesia. Also, keepers are now required to speak in person to veterinarians if they have serious concerns about an animal's recovery.

In November 2002, Phoenix, a 23-year-old female bobcat who was lame, was euthanized because her kidney disease had worsened, Murray said. The life expectancy of bobcats in zoos ranges from the mid-teens to the early thirties.

The pathology report, written by Montali, found that Phoenix's kidneys "were not at end stage." Montali attributed the animal's lameness, in part, to overgrown toenails that had dug into and infected the pads of her front paws.

Again, there are two versions of veterinary records.

The earlier version was printed out five days after the bobcat's death by pathologist Nichols, who participated in the postmortem. It has a Feb. 24, 2002, entry by a staff veterinarian stating that Phoenix's condition should be monitored and that vets should "re-check in three to six months."

The later version of records, which the zoo provided to The Post early this year, has additional entries that bolster Murray's assertion that Phoenix was euthanized because her quality of life had deteriorated.

The added entries include one with Murray's initials that also is dated Feb. 24. "Keepers would like to keep her comfortable and eating as long as possible," the entry states. "When her quality of life is no longer acceptable, keepers to contact vets. Advised that this could happen quickly."

On Nov. 16, keepers wrote that the bobcat had a "severe limp" in her left front leg. Five days later, the animal was euthanized.

The earlier version of veterinary records has a Nov. 20 entry that says keepers "have elected for euthanasia" because of the animal's poor quality of life and poor prognosis through the winter.

The later version has an extra entry for that date, initialed by Murray, that describes several problems not reflected in keeper records for the time period, such as: "She appears hunched over at times . . . with trembling of hind legs."

Murray and keepers strongly disagree with Montali's findings. Murray said: "The bobcat was not euthanized for a limp. . . . She was dying of kidney failure."

In August 2002, a Micronesian kingfisher was rushed to the zoo hospital in a weak condition, with labored breathing. The bird, one of only 60 or so in the world, was treated with fluids and later force-fed a baby mouse, according to a pathology report written by Nichols.

The bird was found dead at the hospital the next day -- with the mouse lodged in its throat.

The cause of death was determined to be West Nile Virus. Nichols questioned the hospital's actions in his letter. "Wouldn't a competent veterinarian have realized that this was a very large and difficult to digest meal for a small bird in respiratory distress?" he asked.

There is a only one entry in the veterinary record for the bird's brief stay at the hospital. But that entry has two versions.

The earlier version, which Nichols printed out three months after the bird's death, said the kingfisher arrived at the hospital "weak/anemic."

That observation has been deleted in a second version printed out much later by Nichols, who was present at the postmortem. The later version has a new entry, bearing Murray's initials, that says only that veterinarians prescribed an antifungal drug.

Two young Grevy's zebras, Buumba and Har, died about a week apart in the winter of 2000. Pathology reports showed that they had virtually no stores of body fat.

Spelman, then the zoo's head veterinarian, supervised the care of 18-month-old Buumba and two other zebras kept at the main zoo. She was not directly involved with Har, who was at the zoo's conservation center in Front Royal, Va.

There are no entries in the veterinary records on Buumba for eight months leading up to the day before he died. There are no entries on 8-year-old Har in the 22 months before his death. The zoo has said veterinarians did not treat the two zebras during those periods. Zebras can live 40 years in captivity.

In a recent letter to the Academy of Sciences, Stuart Wells, then the zoo's zebra curator, said he and his staff asked Spelman to look at Buumba in November 1999 because the zebra seemed ill. Spelman did not examine the zebra, which would have required anesthetizing him. Wells said Spelman cut the diet of all three zebras in half, saying the animals looked fat and might develop hoof problems.

Wells said Spelman did not come back to check on the zebras until Jan. 31, the day before Buumba died. On their own, he said, he and the keepers restored the full zebra diet in December. Wells said he and his staff kept calling the veterinarians to report that Buumba was still sick.

On Jan. 31, 2000, "I called Lucy myself and said the animal looks like hell," Wells said in an interview.

Spelman came early that afternoon. Her veterinary records note that Buumba had severe weight loss and should be examined "ASAP." But because of the time of day and the cold weather, she wrote, she planned to do the examination the next morning.

Wells said Spelman talked about coming back in another week or so, not the next day, if the zebra did not look better.

According to Wells's letter and keeper records, Spelman then ordered another reduction in the diet of the two other zebras at the zoo, saying they "still looked heavy."

An hour later, Buumba was found lying in his stall, unable to get up. Spelman and another veterinarian rushed back, sedated him, took blood and administered fluids. Buumba was left alone overnight in a cold stall and was dead the next morning.

Food for the surviving zebras was immediately increased.

Spelman said ultimate responsibility for the day-to-day care of zoo animals, including the feeding, rests with the keepers and curatorial staff.

"It was not my responsibility to make sure that the keepers have the best husbandry," she said last week.

An internal zoo report, co-authored by Nichols in February 2000, found that Spelman was partly responsible for Buumba's death because she had ordered that the food for all three zebras at the zoo be cut in half. Nichols said Spelman told him that she had cut the diet for the three zebras but that she did it earlier, in the fall of 1999.

Spelman now says the curator and the keepers misunderstood her spoken diet order, which she says was for a different zebra, not Buumba, and meant for only a short time. "I did not recommend that the zebras be on a reduced diet during the winter, absolutely not," she said.

Wells said that, in retrospect, he wishes he had challenged Spelman on the zebras' care.

"At most zoos, the vet is the boss," said Wells, who left the zoo in 2001 after nearly 10 years. "That was certainly the case with Lucy."

After the deaths of Buumba and Har, the zoo improved the quality of its zebra food, made the barns warmer and installed scales so the animals could be weighed.

Pensi, a Sumatran orangutan, had surgery to remove a cancerous intestinal tumor in January 2000 and was fine for several months, according to veterinary records. But in May, the orangutan started having diarrhea and seemed "a bit depressed," wrote Spelman, then head veterinarian.

In July 2000, as Pensi's diarrhea worsened, keepers collected several stool samples and sent them to the lab for tests.

When the animal remained sick, zoo staff members faced a difficult decision.

Given Pensi's age, 32, the curator and keepers decided that if the cancer came back, they would request euthanasia for Pensi rather than subject her to more surgery. Most orangutans live into their forties.

On July 28, the curator and keepers gathered at the Ape House. There was a "consensus" to euthanize the orangutan because they believed that her persistent diarrhea was caused by a recurrence of cancer, according to the euthanasia form signed by Spelman.

Lisa Stevens, the curator, said in a recent interview that she asked for one last test, an ultrasound, to check for signs of cancer, before Pensi was put down. Stevens said she and a handful of keepers watched Spelman do the exam.

"Lucy thought the liver looked abnormal," Stevens said. "It confirmed for us that her cancer had metastasized to the liver."

Spelman said last week that she does not recall doing the ultrasound. "I don't remember. I have racked my brain over this one," she said. Later in the interview, she said, "You know, I may have said her liver looks funny to me."

Pensi was euthanized that day.

A pathology report said the animal's liver was cancer-free. The report said the diarrhea was caused by salmonella, bacteria that could have been detected if a simple fecal test had been done -- but Spelman never ordered one. The lab tests that were done were for parasites.

"To discover that we were dealing with an infection that was treatable was devastating," Stevens said.

In the animal's euthanasia form, Spelman wrote that Pensi had suffered from chronic diarrhea, "non-responsive to medicine," since the cancer surgery.

Stevens said she has "a problem" with that description. Pensi, she said, "did really well for three months before the diarrhea started. Obviously, we didn't give the diarrhea a chance in terms of treating it with the scope of medicines that were available for salmonella."

Stevens also was concerned that Spelman's veterinary records do not state that an ultrasound was done. Rather, the entry says such a test would not have helped diagnose the cancer and would have been difficult to read because of scarring from the previous surgery.

"It doesn't say that an ultrasound test was done, so it doesn't reflect what happened that day," Stevens said.

Caring for animals in a zoo setting is complex, Stevens said, adding: "I'd like to sit here and say we do the job perfectly all the time, but we don't. We're always learning. Pensi's death is something that we've learned from, and we certainly take what we learned from that to heart and will apply it in our future decision-making process."

Charles Benson, chief of the clinical veterinary laboratory at the University of Pennsylvania, reviewed the records of Pensi's case at the request of The Post and said undiagnosed salmonella could have spread to the entire ape colony.

The records, he said, "don't make it clear that an ultrasound was done before the decision to euthanize was made. I would think the zoo would make a better effort to keep the records straight."

Last week, Spelman said that "treating her for salmonella would not have changed the outcome. She had malignant cancer. I don't think anything differently could have been done for Pensi."

Staff writer D'Vera Cohn, researcher Bobbye Pratt and news aide Terence McArdle contributed to this report.

Tomorrow: The death of Nancy the elephant.

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