A series of events involving misinformation, poor communication, and interpersonal conflict within and between the mammal department and curator, management, and veterinary staff at the Toledo Zoo led to the inadvertent denning up of a healthy 18-year-old female sloth bear without food or water for a period of almost three weeks in preparation for cubbing. This led to her death by dehydration on 4 December 2000. Internal inquiries as well as a United States Department of Agriculture (USDA) investigation and inspection ensued. Details of the event and aftermath are discussed below.
The Toledo Zoo has maintained and reproduced several bear species over its 100-year history. Sloth bears, however, were a relatively new species to this institution, the first sibling pair arriving from Poland in 1997. The second female ever brought to Toledo Zoo per Species Survival Plan (SSP) recommendations for breeding arrived in April 1999. She had cubbed successfully at her previous institution in 1996.
The Toledo Zoo has long-established standard denning protocols used successfully for other hibernating species of bears (namely American black bears [Ursus americanus], and polar bears [Ursus maritimus]) for the cubbing period. These include isolating the pregnant female from her exhibit and exhibit-mates in a dark, quiet, secluded holding area with minimal keeper contact or disturbance. This is meant to simulate natural denning/hibernating conditions, minimize disturbance during this time, and reduce the chance that such stress will cause cannibalization of the cubs by the mother. Food and water are offered daily.
This breeding female sloth bear was denned up using this protocol in the fall of 1999 when breeding behavior was seen between the pair and she was speculated to possibly be pregnant. She was denned in a holding area adjacent to the exhibit and was free to move about into an adjacent small outside holding cage away from the exhibit and the male. Food and water were offered daily. No cubs were produced, and she was noted to remain active throughout the denning period.
Events Surrounding the Incident
The female sloth bear had again bred in the summer of 2000. Plans to discuss denning her up were placed on the veterinary department/large mammal department monthly rounds agenda by the senior veterinarian prior to his departure for field work from 13 November to 21 November 2000.
On 20 November, the associate veterinarian received a distressed call from the sloth bear keeper informing her for the first time that the animal had already been denned up as of 17 November 2000, and that plans were to withhold food and water as well to minimize any keeper contact as directed by the mammal curator.
These plans were discussed at large mammal/veterinary rounds on 21 November by the mammal curator, mammal keepers, and the associate veterinarian. The mammal curator stated that he did not plan to give any more food or water other than what was given on 17 November 2000, and that the keepers should only be checking the female once per week to minimize disturbance. He was then questioned by the veterinarian and keepers as to the safety of this change in denning protocol, especially regarding withholding water and reduced frequency of monitoring. He stated that he had discussed this protocol with the previous holding institution and that this was how they had done it, resulting in successful cubbing. He also alluded to other facilities that used this protocol. There was further discussion of placing a remote monitoring device in the den for better monitoring, which the curator said he would address.
The associate veterinarian informed the senior veterinarian upon his return on 22 November 2000. The conversation included a discussion of whether a warm climate bear would undergo a state of dormancy. Since both veterinarians’ experiences included only hibernating species, the associate veterinarian called the previous holding institution’s veterinarian to double-check on their protocol. A message was left with one of their veterinarians. Miscommunication between the Toledo veterinarians was later discovered in that the senior veterinarian did not understand from the conversations that the bear was actually denned up at that time but thought that discussions were in reference to future denning protocol.
The reply from the previous holding facility was not received by the associate veterinarian until 29 November 2000 due to her absence during the holiday interim and family illness. The message received stated that the institution previously holding the bear did not withhold food or water when they denned this or any other bear.
This message was passed on to the mammal curator and the senior veterinarian asking for further clarification or justification to proceed with the protocol the mammal curator had mandated. The assumption was that the bear would be checked, and water offered as a minimum until further information could be verified. The bear had been denned up for 13 days at this point.
On 4 December 2000 the sloth bear was discovered dead in her den by one of the mammal keepers and the curator who had come to check on the animal and feed and water her. It had been 18 days since she had been denned up. Gross necropsy findings indicated a nonpregnant animal whose cause of death was dehydration. The mammal curator did confirm that he had received the message from the veterinarian and took full responsibility for the death of the animal. The director and deputy director, and the mammal curator’s immediate supervisors, reportedly had not been informed of any of the protocols for the sloth bear denning before its death was reported to them.
There was extensive media coverage of the incident, followed by internal (Toledo Zoological Board), USDA, and local humane society investigations. A full USDA inspection of the zoo was also conducted as a result. Several violations of the Animal Welfare Act were cited, three in relation to the sloth bear death. These violations cited by the USDA Animal and Plant Health Inspection Service (APHIS) include noncompliance in the following areas:
9 CFR 3.129 (a)&(b) Feeding
9 CFR 3.130 Watering
9 CFR 2.40 (a) (2) Veterinary care
The veterinarian lacked proper authority to ensure the provision of adequate veterinary care and oversee the adequacy of other aspects of animal care and use. The mammal curator resigned his position. The zoo sustained a fine from the USDA.
The zoo took steps to prevent problems of this nature in the future by evaluating and adopting several new procedural protocols under the direction of the senior veterinarian and deputy director.
1. Set policy that all animal care staff, including veterinarians, curators, and zookeepers, understand that they are to inform the deputy director of any situation that could negatively impact the welfare of any zoo animal. These situations might include housing, feeding, transport, psychologic stress, environmental conditions, medical conditions, and animal safety issues.
2. Written policy that each animal will be observed daily unless exempted by prior written approval of the curator, the veterinarian, the deputy director, and the executive director or for circumstances specified as appropriate in an approved species management plan such as nesting birds, groups of birds, reptiles, amphibians, and fish in natural enclosures where daily observation is not possible, and reptiles and amphibians in hibernation and aestivation.
3. The protocol for any isolation of an animal must include plans for regular visual inspection, either directly or through video monitors, noting that practices specified in an approved management plan as routine and/or appropriate do not require prior approval.
4. Enforced requirement of a completed “Diet Change Request” form submitted to the veterinary department for approval before any radical diet changes are implemented for husbandry or medical reasons.
5. Set policy that the withholding of food and water from any animal in the zoo is prohibited without prior written approval of the curator, veterinarian, the deputy director, and the executive director except for the following:
a. When deemed medically necessary by the veterinarian, such as fasting for newborns or in preparation for anesthesia or for treatment of gastrointestinal problems.
b. Under circumstances specified as appropriate in an approved species management plan, such as part of an animal’s normal husbandry regime or short-term fasting of food for training purposes. Requests for approval must be accompanied by a diet change request.
c. Species fact sheets are to be filled out for each species in the collection. These are to be made available to the veterinary, animal care, and management staff for reference at any time. These will include basic natural history, behavioral, and husbandry information (or cite references in that regard), and management plans for the species in the collection
d. Periodic internal or “self” inspections of different animal areas (including non-mammal and veterinary areas) by a committee made up of the deputy director, veterinarian, curatorial, and maintenance staff. A checklist based on USDA inspection guidelines was drawn up and is to be used as a guide. These inspections will be done semiannually once all the areas have been done.
The loss of an animal under one’s care is often difficult to accept, especially when a well-intentioned, knowledgeable, caring staff is involved. The fact that the sloth bear’s death was a preventable loss made it even more difficult. It was devastating to many staff members and came on the heels of another near tragic elephant keeper injury incident.
Although the incident (in conjunction with the elephant keeper injury which occurred prior to this) served to bring to light the problems of a dysfunctional department with internal morale problems and communication breakdown, and illustrated just how serious the consequences of these problems can become without proper management guidance and communication, some good has come from it.
The roles, rights, authority, and responsibility of the attending veterinarians, management, and animal care staff have become better defined. Communication lines are opening between management and animal care staff, and animal care staff and the veterinary department. The attending veterinarians have been empowered to act when potential animal welfare issues are found and seek assistance from the USDA if their recommendations in that regard are being ignored. It has also stimulated healthy dialogue between the veterinarians, management, and animal care staff to better define what is meant by “adequate veterinary care” as stated in the Animal Welfare Act.