From their report:
"That is why thecomplete regulatory collapse that occurred here is so inexcusable. It should have takenonly one look. The first line of defense was the Pennsylvania Department of Health. The department’s job is to audit hospitals and outpatient medical facilities, like Gosnell’s, tomake sure that they follow the rules and provide safe care. The department had contactwith the Women’s Medical Society dating back to 1979, when it first issued approval toopen an abortion clinic. It did not conduct another site review until 1989, ten years later.Numerous violations were already apparent, but Gosnell got a pass when he promised tofix them. Site reviews in 1992 and 1993 also noted various violations, but again failed toensure they were corrected.But at least the department had been doing something up to that point, howeverineffectual.
After 1993, even that pro forma effort came to an end. Not because of administrative ennui, although there had been plenty. Instead, the
PennsylvaniaDepartment of Health abruptly decided, for political reasons, to stop inspecting abortion clinics at all. The politics in question were not anti-abortion, but pro. With the change of administration from Governor Casey to Governor Ridge,
officials concluded that inspections would be “putting a barrier up to women” seeking abortions.
Better to leave clinics to do as they pleased, even though, as Gosnell proved, that meant both women and babies would pay. The only exception to this live-and-let-die policy was supposed to be forcomplaints dumped directly on the department’s doorstep. Those, at least, would beinvestigated.
Except that there were complaints about Gosnell, repeatedly. Severaldifferent attorneys, representing women injured by Gosnell, contacted the department. Adoctor from Children’s Hospital of Philadelphia hand-delivered a complaint, advising thedepartment that numerous patients he had referred for abortions came back from Gosnellwith the same venereal disease. The medical examiner of Delaware County informed the department that Gosnell had performed an illegal abortion on a 14-year-old girl carryinga 30-week-old baby. And the department received official notice that a woman namedKarnamaya Mongar had died at Gosnell’s hands. Yet not one of these alarm bells – not even Mrs. Mongar’s death – prompted thedepartment to look at Gosnell or the Women’s Medical Society. Only after the raidoccurred, and the story hit the press, did the department choose to act. Suddenly therewere no administrative, legal, or policy barriers; within weeks an order was issued toclose the clinic. And as this grand jury investigation widened, department officials“lawyered up,” hiring a high-priced law firm to represent them at taxpayer expense. Hadthey spent as much effort on inspection as they did on attorneys, none of this would havehappened to begin with.But even this total abdication by the Department of Health might not have beenfatal. Another agency with authority in the health field, the Pennsylvania Department of State, could have stopped Gosnell single-handedly. While the Department of Healthregulates facilities, the Department of State, through its Board of Medicine, licenses andoversees individual physicians. Like their colleagues at Health, however, Department of State officials were repeatedly confronted with evidence about Gosnell, and repeatedlychose to do nothing.Indeed, in many ways State had more damning information than anyone else.Almost a decade ago, a former employee of Gosnell presented the Board of Medicinewith a complaint that laid out the whole scope of his operation: the unclean, unsterileconditions; the unlicensed workers; the unsupervised sedation; the underage abortionpatients; even the over-prescribing of pain pills with high resale value on the street.
The department assigned an investigator, whose investigation consisted primarily of an offsiteinterview with Gosnell.
The investigator never inspected the facility, questioned otheremployees, or reviewed any records. Department attorneys chose to accept thisincomplete investigation, and dismissed the complaint as unconfirmed.Shortly thereafter the department received an even more disturbing report – abouta woman, years before Karnamaya Mongar, who died of sepsis after Gosnell perforatedher uterus. The woman was 22 years old. A civil suit against Gosnell was settled foralmost a million dollars, and the insurance company forwarded the information to thedepartment. That report should have been all the confirmation needed for the complaintfrom the former employee that was already in the department’s possession. Instead, thedepartment
attorneys dismissed this complaint too. They concluded that death was justan “inherent” risk, not something that should jeopardize a doctor’s medical license. The same thing happened at least twice more: the department received complaintsabout lawsuits against Gosnell, but dismissed them as meaningless. A departmentattorney said there was no “pattern of conduct.” He never bothered to check a nationallitigation database, which would have shown that Gosnell had paid out damages to atleast five different women whose internal organs he had punctured during abortions.Apparently, the missing piece in the “pattern” was press coverage. Once that began, afterthe raid, the department attorney quickly managed to secure a license suspension againstGosnell.Similar inaction occurred at the municipal level.
The Philadelphia Department of Public Health does not regulate doctors or medical facilities; but it is supposed to protectthe public’s health. Women’s Medical Society to retrieve blood samples for testing purposes, but nevernoticed, or more likely never bothered to report, that anything was amiss. Anotheremployee inspected the clinic in response to a complaint that dead fetuses were beingstored in paper bags in the employees’ lunch refrigerator. The inspection confirmednumerous violations of protocols for storage and disposal of infectious waste. But nofollow-up was ever done, and the violations continued to the end.A health department representative also came to the clinic as part of a citywidevaccination program. She promptly discovered that Gosnell was scamming the program;more importantly, she was the only employee, city or state, who actually tried to dosomething about the appalling things she saw there. By asking questions and pokingaround, she was able to file detailed reports identifying many of the most egregiouselements of Gosnell’s practice. It should have been enough to stop him. But instead herreports went into a black hole, weeks before Karnamaya Mongar walked into theWoman’s Medical Society.Ironically, the doctor at CHOP who personally complained to the PennsylvaniaDepartment of Health about the spread of venereal disease from Gosnell’s clinic, thedoctor who used to refer teenage girls to Gosnell for abortions, became the head of thecity’s health department two years ago. But nothing changed in the time leading up toMrs. Mongar’s death. And it wasn’t just government agencies that did nothing.
Grand Jury Report Kermit Gosnell Womens Medical