NEIGHBORHOODS DEPARTMENT ANIMAL CARE & PROTECTIVE SERVICES DIVISION

MEMORANDUM

DATE: TO: FROM:

October 23, 2012 File Scott Trebatoski, Division Chief Incident Review Euthanasia of A776518 & A776536

RE:

Event: Four kittens were brought in by a foster caregiver (a recent former employee) to be transferred to another foster caregiver. Two were successfully transferred to one foster caregiver, but two were euthanized prior to being transferred to a second caregiver. There was a second caregiver identified willing to accept the kittens.

Incident Review: Prior to the incident, when the kittens first came in Friday, September 14 in the afternoon, they were not fully weaned. However, it appeared to the intake officer like they were trying to eat wet cat food. If the kittens were identified by the officer as not able to fully eat on their own, that officer would have contacted the adoption/rescue/foster coordinator to try to find a foster home by the close of business that day or the kittens would have been euthanized for humane reasons. The kittens appear to only have been handled by the newly trained officer in intake. Although there was a veterinary technician assigned to the intake area, it is unclear as to why she did not process these kittens and make a decision as to whether they were eating on their own or not. The officer assigned the kittens to a cage and moved them. This normally would have been handled by a kennel staff member but due to the greater than normal intake, the officer had to cover that duty. The officer, who was in training in intake, did not put a vet eval notation in the computer, which would have flagged veterinary staff to look at the animals the next morning. The next day, Saturday, when only on veterinary technician is assigned to work, the tech did not see the kittens in the morning because they were not on vet eval. She did evaluate them in the late afternoon but did not identify anywhere in the notes as to whether they were able to eat on their own or not. The weight of the kittens should have been a flag to the potential of them not eating on their own; this was a failure by the vet tech to follow all established protocol. Had the technician identified that the kittens were not able to fully eat on their own, protocol would have required euthanasia if there was no foster caregiver at the shelter by close of business that day. The kennel supervisors regular days off were Friday and Saturday. The kennel supervisor had noticed the kittens were thin and did not appear to be eating on their own (identified by only scrape marks made by teeth in the wet food not bites taken out of it). She noticed that the kittens had been in the shelter two days and proper protocol was not followed to euthanize the kittens without a mother, not eating on their own, and having no foster caregiver. The supervisor hand fed the kittens a few times that day but said the kittens were very thin. The decision was th made to euthanize the kittens Sunday, September 16 . The supervisor approved keeping the kittens one more night in the shelter because she was told that a foster caregiver could be found Monday morning. A kennel worker arranged to take the kittens.
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NEIGHBORHOODS DEPARTMENT ANIMAL CARE & PROTECTIVE SERVICES DIVISION

When the kittens were first brought back in by the foster caregiver, they were handled per protocol by having the foster caregiver contact the adoption/rescue/foster coordinator who in turn entered the kittens back into the system. The kittens were listed as: brought in from foster with the current condition of nursing. At that time, no hold was placed on the kittens and they were kept in the front office area; they were not assigned a kennel/cage. This was approximately 10:16 st a.m. on Friday, September 21 . It should be noted that the foster caregiver was also a recent former employee affected by reduction in force and that she lives with the current kennel worker that took the kittens home a few days prior. At 10:30 a.m., a hold was placed on the kittens by the volunteer/foster caregiver/former employee but established protocol of placing notes with the hold designation was not followed. This is the first time the organization has had a volunteer who had access to the shelter software and was allowed to enter any information. However she was allowed to do so by the front office staff because she was a former employee. The kittens were taken back to the kennel and assigned a cage designation of 305 by the volunteer/foster caregiver/former employee. It is unclear as to whether that person also physically took the kittens back to the cage or if it may have been her live-in boyfriend, who is a current employee. If the volunteer/foster caregiver/former employee took the kittens back to the kennel it would have been a deviation from established standard operating procedures; if it was her boyfriend it would have followed protocol except for the assignment of the particular room. The kittens were very quickly thereafter moved to 805 which was more in line with protocol and the record was updated by the volunteer/foster caregiver/former employee. The same volunteer/former employee arranged new foster caregivers for the kittens and ultimately processed them in the system (again, not a function that a volunteer is normally allowed to perform). The first two of the four kittens, A776517 and A776521, were transferred to a foster caregiver. The second two kittens were euthanized by a veterinary technician before they were transferred to the foster caregiver. Apparently, the foster caregiver was in the building at or near the time these kittens were euthanized. Although there were no notes indicating that foster caregivers had been identified and were coming to pick up the kittens there was a hold placed on them. When the veterinary technician saw these very small kittens in a cage without access to the food and water, which was placed on the second tier of the cage inaccessible by the small kittens, and she identified that the kittens were underweight; she made the decision to remove the hold from the kittens because they appeared to be unable to eat on their own and there was not mother with them. Holds are only supposed to be removed either by the person who placed the original hold, by the adoption/rescue coordinator, or by a supervisor/manager. So, although the identification of kittens not fully eating on their own and without a mother (and brought in that very morning about one hour prior) was a flag to warrant protocol for potential euthanasia of the kittens for humane reasons, the hold should have been investigated and only removed by an approved person.

Findings/Recommendations: The protocol currently in place should have been sufficient to avoid this tragic event from taking place. A series of errors and failure to follow policies, procedures and protocol short circuited the system. Major revisions to the systems in place are not necessary to avoid a similar incident in the future. Review of various policies and protocol with the entire staff are recommended for the next possible staff meeting. A new provision has been added to protocol for making euthanasia decisions in the future. In addition to the existing three employee screening team for normal decision making for daily euthanasia, a minimum of two employees, which should include a supervisor if available, must agree that an animal should be euthanized before such action is

NEIGHBORHOODS DEPARTMENT ANIMAL CARE & PROTECTIVE SERVICES DIVISION

taken. If the euthanasia is after hours and only one employee is present, that employee must try to make contact with the shelter veterinarian to confer on the euthanasia decision. If the veterinarian is unavailable, the employee must contact a manager or supervisor to assist in making the euthanasia decision.

Remedial Actions to be Taken: 1. In accordance with City policy fact finding, meetings should be scheduled with all employees involved in the incident to determine if there are any formal disciplinary actions that should be taken. 2. Retraining of all staff on the existing protocols along with the new additions should be done as soon as practical.