After Snooty’s tragic death in July, the At The Bishop made a promise to the community to examine — with the help of outside experts — whether there were failures of physical facilities, whether there were human errors and whether appropriate policies and operating procedures were in place and followed.

On Aug. 31, Museum officials thanked the community for its patience while the Board of Trustees conducted this evaluation and shared the results from the report and the details of the changes the Museum is making in the wake of the serious findings it contains.

When the Museum’s Board of Trustees sought outside expertise to conduct a thorough review of what happened, James Gesualdi was the top recommendation. Mr. Gesualdi is an attorney and nationally recognized animal welfare advocate who wrote the book “Excellence Beyond Compliance.”

The Board of Trustees was committed to leaving no stone unturned in their pursuit of finding out what happened and taking actions to prevent any similar occurrence from ever happening again, and felt confident that Mr. Gesualdi would provide answers and advocate on Snooty’s behalf.

Snooty died when an access panel blocking an underwater plumbing area in his habitat came off at some point on the night of July 22 or the morning of July 23 and that Snooty swam into the opening, was unable to get out and drowned.

Mr. Gesualdi conducted a site review and interviewed more than a dozen Museum staff, including all manatee care team members, key facility staff, executive staff and the consulting veterinarian who cared for Snooty for more than 20 years. He also reviewed Museum records, documents, photos, videos and security footage.

During a thorough review process, the Museum discovered that Aquarium staff were aware of the panel being loose or askew, or that it was missing screws, beginning Sunday, July 16 — a week before Snooty’s death. Due to breakdowns in record keeping, reporting, communication and follow-through — while some action was taken no action culminated in an effective repair.

Sadly, Snooty’s death was the result of a preventable accident and several factors contributed to this tragedy — factors the Museum is actively addressing today, including:

• Deficiencies in record keeping and reporting;
• A breakdown within departmental communications;
• A lack of proactive follow through;
• The need for improved staff training.

To address the breakdowns that contributed to this tragic accident, the Museum is:

• Making changes in staffing;
• Retraining and cross-training Aquarium and facility staff on inspecting and assessing the habitat;
• Developing new dive checklists;
• Instituting new record keeping, reporting and communications protocols;
• Putting in place a new work order system for maintenance, repairs, and coordinating assistance from other departments.

The Board of Trustees is confident that the Museum’s executive staff has done a thorough job of analyzing the facts to understand what went wrong, has acted swiftly and appropriately to implement new procedures and restructure staff to make sure an incident like this never happens again.

“On behalf of the Museum, I apologize for the mistakes that led to Snooty’s death,” said Brynne Anne Besio, Museum CEO. “We have made, and continue to make, substantive changes — operationally and philosophically — to address the breakdowns that contributed to this tragic accident.  Snooty brought joy to all millions of lives and the Museum remains committed to ensuring that his voice continues to inspire support for manatee rehabilitation, conservation and education for generations to come.

“I hope that the community will join us on Sept. 10 to help us honor his legacy during a special memorial open house.”

To request a copy of the official report, email JSchubick@SouthFloridaMuseum.org.