So how did Dr. Gosnell get away with all this? How could he have run his house of horrors for years without getting caught? The answer can be found in the next section of the Grand Jury’s report. We’ve already covered their report on what Gosnells clinic was like, his murder of children, and his criminal malpractice against his patients. You can find the report in it’s entirety here.
“See no evil
Pennsylvania is not a third-world country. There were several oversight agencies that stumbled upon and should have shut down Kermit Gosnell long ago. But none of them did, not even after Karnamaya Mongar’s death. In the end, Gosnell was only caught by accident, when police raided his offices to seize evidence of his illegal prescription selling. Once law enforcement agents went in, they couldn’t help noticing the disgusting conditions, the dazed patients, the discarded fetuses. That is why the complete regulatory collapse that occurred here is so inexcusable. It should have taken only 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, to make sure that they follow the rules and provide safe care. The department had contact with the Women’s Medical Society dating back to 1979, when it first issued approval to open 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 to fix them. Site reviews in 1992 and 1993 also noted various violations, but again failed to ensure they were corrected.
But at least the department had been doing something up to that point, however ineffectual. After 1993, even that pro forma effort came to an end. Not because of administrative ennui, although there had been plenty. Instead, the Pennsylvania Department 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 for complaints dumped directly on the department’s doorstep. Those, at least, would be investigated. Except that there were complaints about Gosnell, repeatedly. 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 Gosnell.
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 because the subject was the political football of abortion.”
Dr. Gosnell is a mass murderer, and his crimes will undoubtedly be punished. But who will punish those who let him get away with murder? Shame on the Pennsylvania Department of Health, shame on the Pennsylvania Department of State, shame on the officials who ordered inspections to be stopped for political reasons, and shame on the National Abortion Federation evaluator who did not speak out after inspecting his appalling facility. Dr. Gosnell should have been shut down more than a decade ago.
It is horrific enough, as we saw last week (to start at the beginning click here) to hear how Dr. Glosnell murdered countless babies in cold blood. But even his patients, the women who he was supposedly trying to help, were not safe from his criminal negligence and malpractice. This next section of the Grand Jury’s Report overviews this aspect of his crimes, and how he killed one of at least two women who died because of his “care.” If you’d like to read the entire report you can find it here.
“Butcher of women
Dr. Gosnell didn’t just kill babies. He was also a deadly threat to mothers. Not every abortion could be completed by inducing labor and delivery. On these occasions, Gosnell would attempt to remove the fetus himself. The consequences were often calamitous – though that didn’t stop the doctor from trying to cover them up.
One woman, for example, was left lying in place for hours after Gosnell tore her cervix and colon while trying, unsuccessfully, to extract the fetus. Relatives who came to pick her up were refused entry into the building; they had to threaten to call the police. They eventually found her inside, bleeding and incoherent, and transported her to the hospital, where doctors had to remove almost half a foot of her intestines.
On another occasion, Gosnell simply sent a patient home, after keeping her mother waiting for hours, without telling either of them that she still had fetal parts inside her. Gosnell insisted she was fine, even after signs of serious infection set in over the next several days. By the time her mother got her to the emergency room, she was unconscious and near death.
A nineteen-year-old girl was held for several hours after Gosnell punctured her uterus. As a result of the delay, she fell into shock from blood loss, and had to undergo a hysterectomy.
One patient went into convulsions during an abortion, fell off the procedure table, and hit her head on the floor. Gosnell wouldn’t call an ambulance, and wouldn’t let the woman’s companion leave the building so that he could call an ambulance.
Undoubtedly there were many similar incidents, but even they do not demonstrate Gosnell at his most dangerous. Day in and day out, the greatest risks came when the doctor wasn’t even there. 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 completely unsafe.
Only in one class of cases did Gosnell exercise any real care with these dangerous sedatives. On those rare occasions 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.” Karnamaya Mongar was not one of the privileged patients. She was a 41-yearold, refugee who had recently come to the United States from a resettlement camp in Nepal. When she arrived at the clinic, Gosnell, as usual, was not there. Office workers had her sign various forms that she could not read, and then began doping her up. She received repeated unmonitored, unrecorded intravenous injections of Demerol, a sedative seldom used in recent years because of its dangers. Gosnell liked it because it was cheap.
After several hours, Mrs. Mongar simply stopped breathing. When employees finally noticed, Gosnell was called in and briefly attempted to give CPR. He couldn’t use the defibrillator (it was broken); nor did he administer emergency medications that might have restarted her heart. After further crucial delay, paramedics finally arrived, but Mrs. Mongar was probably brain dead before they were even called. In the meantime, the clinic staff hooked up machinery and rearranged her body to make it look like they had been in the midst of a routine, safe abortion procedure.
Even then, there might have been some slim hope of reviving Mrs. Mongar. The paramedics were able to generate a weak pulse. But, because of the cluttered hallways and the padlocked emergency door, it took them over twenty minutes just to find a way to get her out of the building. Doctors at the hospital managed to keep her heart beating, but they never knew what they were trying to treat, because Gosnell and his staff lied about how much anesthesia they had given, and who had given it. By that point, there was no way to restore any neurological activity. Life support was removed the next day.
Karnamaya Mongar was pronounced dead.”
Even if media outlets fear that abortion connection might make this story to politically risky, you’d at least think they would be all over the death of a refugee due to criminal malpractice. Yet the media, other than a few editorials in various opinion sections (and kudos to those columnists for speaking up), is burying the story. This should have been first page news and it’s being shoved under the rug. Their cowardice could result in this kind of horrific situation happening again. Because rest assured: Dr. Gosnell should have been stopped long before Karnamaya Mongar died in that emergency room. You’d think that her death would have been all the waning the authorities needed that something was wrong: unfortunately, you’d be wrong. Tomorrow I’ll post the next section of the report, which details the inexcusable negligence of those whose job it is to prevent atrocities like these. If you can’t wait until tomorrow you can find the whole story right here, straight from the Grand Jury of the 1st Judicial District of Pennsylvania.
I wasn’t planning on posting about this. I had a much lighter and more innocent post planned. However, when I found out about this story, and the appalling lack of media attention it’s receiving, my priorities shifted.
Dr. Kermit Gosnell was, until his arrest, the presiding doctor at the Women’s Medical Society clinic in west Philadelphia. He is currently on trial, along with his unlicensed medical assistants, on 7 counts of first degree murder, conspiracy to commit murder, infanticide, and numerous other charges. So far (though there is so hope that public outcry will start to change this) his story has gone mostly unreported by the news media. No doubt, because he was a doctor who performed abortions, some media purveyors are afraid of seeming “anti-choice” by reporting this man’s crimes. Whatever the reason for the media’s silence, this man’s deeds need to be heard. More importantly the world needs to know about the inexcusable negligence on the part of the Pennsylvania Department of Health, the Pennsylvania Department of State, and the National Abortion Federation, all of whom had evidence of Dr. Gosnell’s gross malpractice and yet did nothing to investigate further or shut him down.
I’m not a reporter. But if the news media won’t tell the story than I will. Because I’m not a reporter, however, I won’t write a long article about it. Instead, over the next few days, I will quote the Overview of the Report of the Grand Jury that indicted Dr. Gosnell. It shows the horrors that went on with greater authority and ability than I can on my own.
If you want to confirm these facts for yourself, or wish to read the rest of the report, you can find it here.
“SECTION I: OVERVIEW
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 trimester of pregnancy – and then murdered these newborns by severing their spinal cords with scissors. The medical practice by which he carried out this business was a filthy fraud in which 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.
The “Women’s Medical Society”
That was the impressive-sounding name of the clinic operated in West Philadelphia, at 38th and Lancaster, by Kermit B. Gosnell, M.D. Gosnell seemed impressive as well. A child of the neighborhood, Gosnell spent almost four decades running this clinic, giving back – so it appeared – to the community in which he continued to live and work.
But the truth was something very different, and evident to anyone who stepped inside. 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 procedures, administering drugs.
Because the real business of the “Women’s Medical Society” was not health; it was profit. There were two primary parts to the operation. By day it was a prescription mill; by night an abortion mill. A constant stream of “patients” came through during business hours and, for the proper payment, left with scripts for Oxycontin and other controlled substances, for themselves and their friends. Gosnell didn’t see these “patients”; he didn’t even show up at the office during the day. He just left behind blank, pre-signed prescription pads, and had his unskilled, unauthorized workers take care of the rest. The fake prescriptions brought in hundreds of thousands of dollars a year. But this drug-selling operation is the subject of separate investigation by federal authorities.
Our focus was on the other side of the business.”
I will post the next section of the overview tomorrow, which goes into greater detail about how the clinic operated in plain sight. If you can’t wait until then, I highly recommend reading the full outline here. And if the words above stirred your sense of injustice, post this story everywhere you can. Facebook, Twitter, MySpace, personal blogs, wherever you can. Individuals like you and me have little to lose from a story being politically dangerous. If we don’t get the story out, who will?