From the Grand Jury report issued 1/17/2011: “This case is about a doctor who killed babies and endangered women. What we mean is that he regularly and illegally delivered live, viable, babies in the third trimesterof pregnancy – and then murdered these newborns by severing their spinal cords withscissors. The medical practice by which he carried out this business was a filthy fraud inwhich he overdosed his patients with dangerous drugs, spread venereal disease among them with infected instruments, perforated their wombs and bowels – and, on at least two occasions, caused their deaths. Over the years, many people came to know that something was going on here. But no one put a stop to it.
Let us say right up front that we realize this case will be used by those on both sides of the abortion debate. We ourselves cover a spectrum of personal beliefs about the morality of abortion. For us as a criminal grand jury, however, the case is not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants. We find common ground in exposing what happened here, and in recommending measures to prevent anything like this from ever happening again.”
From the report:
“The clinic reeked of animal urine, courtesy of the cats that were allowed to roam
(and defecate) freely. Furniture and blankets were stained with blood. Instruments were
not properly sterilized. Disposable medical supplies were not disposed of; they were
reused, over and over again. Medical equipment – such as the defibrillator, the EKG, the
pulse oximeter, the blood pressure cuff – was generally broken; even when it worked, it
wasn’t used. The emergency exit was padlocked shut. And scattered throughout, in
cabinets, in the basement, in a freezer, in jars and bags and plastic jugs, were fetal
remains. It was a baby charnel house.
The people who ran this sham medical practice included no doctors other than
Gosnell himself, and not even a single nurse. Two of his employees had been to medical
school, but neither of them were licensed physicians. They just pretended to be.
Everyone called them “Doctor,” even though they, and Gosnell, knew they weren’t.
Among the rest of the staff, there was no one with any medical licensing or relevant
certification at all. But that didn’t stop them from making diagnoses, performing
From the Grand Jury Report: “Gosnell’s approach, whenever possible, was to force full labor and delivery of premature infants on ill-informed women. The women would check in during the day, make payment, and take labor-inducing drugs. The doctor wouldn’t appear until evening, often 8:00, 9:00, or 10:00 p.m., and only then deal with any of the women who were ready to deliver. Many of them gave birth before he even got there. By maximizing the pain and danger for his patients, he minimized the work, and cost, for himself and his staff.”
“Gosnell set up his practice to rely entirely on the untrained
actions of his unqualified employees. They administered drugs to induce labor, often
causing rapid and painful dilation and contractions. But Gosnell did not like it when
women screamed or moaned in his clinic, so the staff was under instruction to sedate
them into stupor. Of course his assistants had no idea how to manage the powerful
narcotics they were using. Gosnell prepared a list of preset dosage levels to be
administered in his absence. But no allowances were made for individual patient
variations, or for any monitoring of vital signs. All that mattered was the money. The
more you paid, the more pain relief you received. It was all completely illegal, and
Only in one class of cases did Gosnell exercise any real care with these dangerous
sedatives. On those rare occasions when the patient when the patient was a white woman from the
suburbs, Gosnell insisted that he be consulted at every step. When an employee asked him why, he said it
was “the way of the world.””
From the report:
“Several different attorneys, representing women injured by Gosnell, contacted the department. A doctor from Children’s Hospital of Philadelphia hand-delivered a complaint, advising the
department that numerous patients he had referred for abortions came back from Gosnell
with 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 carrying
a 30-week-old baby. And the department received official notice that a woman named
Karnamaya Mongar had died at Gosnell’s hands.
Yet not one of these alarm bells – not even Mrs. Mongar’s death – prompted the
department to look at Gosnell or the Women’s Medical Society. Only after the raid
occurred, and the story hit the press, did the department choose to act. Suddenly there
were no administrative, legal, or policy barriers; within weeks an order was issued to
close 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. Had
they spent as much effort on inspection as they did on attorneys, none of this would have happened to begin with.
But even this total abdication by the Department of Health might not have been
fatal. Another agency with authority in the health field, the Pennsylvania Department of
State, could have stopped Gosnell single-handedly. While the Department of Health
regulates facilities, the Department of State, through its Board of Medicine, licenses and
oversees individual physicians. Like their colleagues at Health, however, Department of
State officials were repeatedly confronted with evidence about Gosnell, and repeatedly
chose 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 Medicine
with a complaint that laid out the whole scope of his operation: the unclean, unsterile
conditions; the unlicensed workers; the unsupervised sedation; the underage abortion
patients; 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 offsite
interview with Gosnell. The investigator never inspected the facility, questioned other
employees, or reviewed any records. Department attorneys chose to accept this
incomplete investigation, and dismissed the complaint as unconfirmed.
Shortly thereafter the department received an even more disturbing report – about
a woman, years before Karnamaya Mongar, who died of sepsis after Gosnell perforated
her uterus. The woman was 22 years old. A civil suit against Gosnell was settled for
almost a million dollars, and the insurance company forwarded the information to the
department. That report should have been all the confirmation needed for the complaint
from the former employee that was already in the department’s possession. Instead, the
department attorneys dismissed this complaint too. They concluded that death was just
an “inherent” risk, not something that should jeopardize a doctor’s medical license.
The same thing happened at least twice more: the department received complaints
about lawsuits against Gosnell, but dismissed them as meaningless. A department
attorney said there was no “pattern of conduct.” He never bothered to check a national
litigation database, which would have shown that Gosnell had paid out damages to at
least five different women whose internal organs he had punctured during abortions.
Apparently, the missing piece in the “pattern” was press coverage. Once that began, after
the raid, the department attorney quickly managed to secure a license suspension against
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 protect
the public’s health. Philadelphia health department employees regularly visited the
Women’s Medical Society to retrieve blood samples for testing purposes, but never
noticed, or more likely never bothered to report, that anything was amiss. Another
employee inspected the clinic in response to a complaint that dead fetuses were being
stored in paper bags in the employees’ lunch refrigerator. The inspection confirmed
numerous violations of protocols for storage and disposal of infectious waste. But no
follow-up was ever done, and the violations continued to the end.
A health department representative also came to the clinic as part of a citywide
vaccination program. She promptly discovered that Gosnell was scamming the program;
more importantly, she was the only employee, city or state, who actually tried to do
something about the appalling things she saw there. By asking questions and poking
around, she was able to file detailed reports identifying many of the most egregious
elements of Gosnell’s practice. It should have been enough to stop him. But instead her
reports went into a black hole, weeks before Karnamaya Mongar walked into the
Woman’s Medical Society.
Ironically, the doctor at CHOP who personally complained to the Pennsylvania
Department of Health about the spread of venereal disease from Gosnell’s clinic, the
doctor who used to refer teenage girls to Gosnell for abortions, became the head of the
city’s health department two years ago. But nothing changed in the time leading up to
Mrs. Mongar’s death. And it wasn’t just government agencies that did nothing. The
Hospital of the University of Pennsylvania and its subsidiary, Penn Presbyterian Medical
Center, are in the same neighborhood as Gosnell’s office. State law requires hospitals to
report complications from abortions. A decade ago, a Gosnell patient died at HUP after a
botched abortion, and the hospital apparently filed the necessary report. But the victims
kept coming in. At least three other Gosnell patients were brought to Penn facilities for
emergency surgery; emergency room personnel said they have treated many others as
well. And at least one additional woman was hospitalized there after Gosnell had begun
a flagrantly illegal abortion of a 29-week-old fetus. Yet, other than the one initial report,
Penn could find not a single case in which it complied with its legal duty to alert
authorities to the danger. Not even when a second woman turned up virtually dead.
So too with the National Abortion Federation. NAF is an association of abortion
providers that upholds the strictest health and legal standards for its members. Gosnell,
bizarrely, applied for admission shortly after Karnamaya Mongar’s death. Despite his
various efforts to fool her, the evaluator from NAF readily noted that records were not
properly kept, that risks were not explained, that patients were not monitored, that
equipment was not available, that anesthesia was misused. It was the worst abortion
clinic she had ever inspected. Of course, she rejected Gosnell’s application. She just
never told anyone in authority about all the horrible, dangerous things she had seen.
Bureaucratic inertia is not exactly news. We understand that. But we think this
was something more. We think the reason no one acted is because the women in
question were poor and of color, because the victims were infants without identities, and
DO NOT READ OR LOOK AT THE GRAND JURY DOCUMENT IF YOU ARE SENSITIVE