As she walked to the break room at the San Jose animal shelter earlier this week, a strange beeping noise from an IV pump in the shelter’s medical area drew Courtney Ferro’s attention.

That’s when the animal care attendant, who was working a Monday night shift in the San Jose Animal Care and Services Center’s kitten hut Monday, witnessed what she described as the alarming and traumatic distress of a dog named Lola. Her rump was pressed up against the grate of her kennel, and her legs and neck were tangled up by both an IV line and a leash that had slowly sucked the life out of her, Ferro said.

“When I fully opened the kennel, I realized she had her IV line wrapped around one of her front legs and then her slip lead —  which should not have been on her — was wrapped a dozen or more times around her neck and the other line as well, so she was held in place,” Ferro said. “She had no circulation in one leg and she was also being strangled.”

In her frantic state, Ferro freed the dog, but with no medical staff on-site, she tried to reach management, but failed to get an answer. Eventually, another employee found an animal control officer to transport Lola for emergency medical care.

While she left the building alive, Lola died shortly after —  levying another black eye to the struggling shelter that advocates say continues to be plagued with mismanagement six months after a scathing audit took the city to task for its substandard conditions, inadequate care and overcapacity.

In response to that audit, San Jose Mayor Matt Mahan demanded change and said he would call for new management if he did not see immediate improvements. On Thursday, he followed through on that promise.

“As evidenced by this horrific incident, we continue to have a failure of leadership,” Mahan said. “It’s common sense — frontline workers need to know what to do in moments of crisis. It’s not their failure that they clearly didn’t — this is the failure of their managers to set up proper procedures to ensure we’re doing right by our animals. We need change.”

A barrage of complaints and a surge in animal deaths that prompted the shelter to lose its no-kill label spurred the audit, which confirmed the concern and red flags that advocates had pointed out for years.

While the shelter is in the process of implementing the audit’s 39 recommendations that could improve the welfare of the animals under its care, advocates blasted it last week because they said many issues that led to its decline persist.

“When something happens, it’s treated like it is a one-off, but what it really signals is a lack of policies and procedures, training and accountability,” said advocate Jennifer Flick, who works with Scritch Kittens, a Bay Area rescue group.

After Lola’s death, many questioned whether the shelter failed to follow the Association of Shelter Veterinarians’ guidelines for tethering and emergency medical care.

“You’re never ever supposed to leave an animal unattended with an IV line in, and there was no medical staff at the shelter that evening,” said Rebekah Davis-Matthews, co-founder of Sustain Our Shelters.

Advocates also noted this is not the first time animals have been left with their leashes on at the shelter. For example, a volunteer documented finding one dog’s leash wedged in its kennel door.

Industry guidelines state that shelters should have an emergency management plan that ensures appropriate and timely care, including available staff trained on what to look for and how to report it.

The city said the shelter is staffed with animal services officers on site until 10 p.m., an on-call Animal Services Officer after 10 p.m. and shelter staff on site overnight.

“In the event of an after-hours emergencies, staff are instructed to contact a supervisor for guidance and, if needed, transport animals to MedVet for urgent medical care,” said Deputy Public Information Officer Kari Chinn, a spokeswoman for the shelter. “As part of the internal review, we are evaluating whether these guidelines were followed in this situation and identifying any areas for improvement.”

Chinn said the shelter was committed to an internal review and open to an outside expert looking into the death and delivering accountability if wrongdoing was found.

She said Lola was “emaciated, lethargic, and having difficulty walking” when she was admitted on Monday and evaluated for potential humane euthanasia. Chinn said Lola’s condition improved after lifesaving care was initiated to increase her blood volume and blood sugar, giving her a chance to recover until attendants discovered her under distress later that night.

Adding to the concerns, Ferro said she learned another animal care attendant had contacted a shelter coordinator earlier in the evening about the beeping sound — an indicator that the IV had become detached — that drew her attention. Ferro said the coordinator advised the other attendant to turn off the pump, but did not do so.

The incident added to a consistent pattern of unresponsiveness and lack of management protocols during her short tenure at the shelter, Ferro said.

“I have not been taught or instructed on any sort of emergency plan, and I’ve been worried about if there would be a fire or something else, what to do because I have no written guidebook,” Ferro said. “Almost all of my training has been verbal and not in writing. Most of my emails to management go unanswered if I have questions.”

While Ferro had held out hope that the audit would improve conditions at the shelter, she said Lola’s death has prompted her to reconsider working there unless the city makes profound changes.

“I feel like I’m running into the same poorly managed situations like people experienced in the past, so I just don’t know that any changes occurred, which is really sad,” Ferro said.

Meanwhile, advocates blame this week’s tragedy on shelter management and city officials and say they have grown tired of the performative acts.

“Lola’s death is their fault and they should have changed something,” Flick said. “The animals are suffering and dying. Shifting the blame or playing the ‘we’re the victims’ card just isn’t cutting it anymore.”