Report of the Grand Jury (Gosnell the abortionist)

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. http://www.phila.gov/districtattorney/pdfs/grandjurywomensmedical.pdf

In addition to the linked Jury Report, I took it upon myself to create the following condensed version of the report up to Section VII Criminal Charges.

Pg 1:

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 danger ous 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.

Pg 2:

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.

Pg 2:

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.

Pg 3:

Gosnell catered to the women who couldn’t get abortions elsewhere – because they were too pregnant. Most doctors won’t perform late second-trimester abortions, from approximately the 20th week of pregnancy, because of the risks involved. And late-term abortions after the 24th week of pregnancy are flatly illegal. But for Dr. Gosnell, they were an opportunity. The bigger the baby, the more he charged.

Pg 4:

There remained, however, a final difficulty. When you perform late-term “abortions” by inducing labor, you get babies. Live, breathing, squirming babies. By 24 weeks, most babies born prematurely will survive if they receive appropriate medical care. But that was not what the Women’s Medical Society was about. Gosnell had a simple solution for the unwanted babies he delivered: he killed them. He didn’t call it that. He called it “ensuring fetal demise.” The way he ensured fetal demise was by sticking scissors into the back of the baby’s neck and cutting the spinal cord. He called that “snipping.”

Pg 6:

Over the years, there were hundreds of “snippings.” Sometimes, if Gosnell was unavailable, the “snipping” was done by one of his fake doctors, or even by one of the administrative staff. But all the employees of the Women’s Medical Society knew. Everyone there acted as if it wasn’t murder at all.

Pg 6:

Gosnell made little effort to hide his illegal abortion practice. But there were some , “the really big ones,” that even he was afraid to perform in front of others. These abortions were scheduled for Sundays, a day when the clinic was closed and none of the regular employees were present. Only one person was allowed to assist with these special cases – Gosnell’s wife. The files for these patients were not kept at the office; Gosnell took them home with him and disposed of them. We may never know the details of these cases.

Pg 5-6:

We do know, however, that, during the rest of the week, Gosnell routinely aborted and killed babies in the sixth and seventh month of pregnancy. The Sunday babies must have been bigger still.

Pg 6:

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 a nd incoherent, and transported her to the hospital, where doctors had to remove almost half a foot of her intestines.

Pg 6:

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.

Pg 6:

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.

Pg 7:

Gosnell set up hi s 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 contrac tions. 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.

Pg 7:

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.

Where are Al Sharpton, Jessie Jackson and the other race baiters?

Pg 8:

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.

Pg 8:

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.

Pg 9:

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.

Pg 10:

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.

Pg 13:

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 a pplication. She just never told anyone in authority about all the horrible, dangerous things she had seen.

Pg 14:

We group the criminal charges into three categories: charge s arising from the baby murders and illegal abortions; charges in connection with the death of Karnamaya Mongar; and charges stemming generally from the ongoing operation of a criminal enterprise.

Pg 15:

As a final note, we charge Gosnell and Tina Baldwin, his employee, with corrupting the morals of a minor. Gosnell hired Tina’s 15-year-old daughter as a staff member. She was required to work 50-hour weeks, starting after school until past midnight, during which she was exposed to the full horrors of Gosnell’s pract ice.

Pg 15:

Worth special mention is Janice Staloski of the Pennsylvania Department of Health, who personally participated in the 1992 site visit, but decided to let Gosnell slide on the violations that were already evident then. She eventually rose to become director of the division that was supposed to regu late abortion providers, but never looked at Gosnell despite specific complaints from lawyers, a doctor, and a medical examiner. After she was nonetheless promoted, her successor as division director, Cynthia Boyne, failed to order an investigation of the clinic even when Karnamaya Mongar died there.

Pg 15-16:

Lawyers at the Pennsylvania Department of State behaved in the same fashion. Attorneys Mark Greenwald, Charles Hartwell, David Grubb, Andrew Kramer, William Newport, Juan Ruiz, and Kerry Maloney were confronted with a growing pile of disquieting facts about Gosnell, including a detailed, inside account from a former employee, and a 22-year-old dead woman. Every time, though, they managed to dismiss the evidence as immaterial.

Pg 17:

The Philadelphia Department of Public Health should do at least as much to control infectious medical waste as it does to inspect swim ming pools and beauty parlors.

Pg 19:

On February 18, 2010, the Federal Bureau of Investigation and detectives from the Philadelphia District Attorney’s Office executed search warrants at the Women’s Medical Society, a clinic operated by Dr. Kermit Barron Gosnell at 3801-05 Lancaster Avenue in Philadelphia. The federal Drug Enforcement Administration (DEA), the Philadelphia Police Department, and the District Attorney’s Dangerous Drug-Offender Unit had been investigating Gosnell and his clinic for months, based on reports of illegal prescription drug activity. During the drug-trafficking investigation, District Attorney’s Detective James Wood learned from one of the clinic employees that a woman had died in November 2009, following an abortion procedure. Detective Wood discovered other disturbing details about Gosnell’s medical practice. The premises were dirty and unsanitary.

Pg 20:

The search team waited outside until Gosnell finally arrived at the clinic, at about 8:30 p.m. When the team members entered the clinic, they were appalled, describing it to the Grand Jury as “filthy,” “deplorable,” “disgusting,” “very unsanitary, very outdated, horrendous,” and “by far, the worst” that these experienced investigators had ever encountered. There was blood on the floor. A stench of urine filled the air. A flea-infested cat was wandering through the facility, and there were cat feces on the stairs. Semi-conscious women scheduled for abortions were moaning inthe waiting room or the recovery room, where they sat on dirty recliners covered with blood-stained blankets.

Pg 20:

No one from these agencies had visited the clinic in more than 15 years, even after the Department of Health had been informed of Mrs. Mongar’s death months earlier.
-snip-
Investigators found the clinic grossly unsuitable as a surgical facility. The two surgical procedure rooms were filthy and unsanitary – Agent Dougherty described them as resembling “a bad gas station restroom.”

Pg 21

The same corroded suction tubing used for abortions was the only tubing available for oral airways if assistance for breathing was needed.
-snip-
The search team discovered fetal remains haphazardly stored throughout the clinic – in bags, milk jugs, orange juice cartons, and even in cat-food containers. Some fetal remains were in a refrigerator, others were frozen.

Pg 22:

The Philadelphia District Attorney submitted this case, pertaining to criminal wrongdoing at Gosnell’s clinic, to the Grand Jury on May 4, 2010.

Someone sure kept a tight lid on this through the 2012 election.

Pg23:

We estimate that Gosnell took in as much as $10,000 to $15,000 a night, mostly in cash, for a few hours of work performing abortions. And this amount does not include the money he made as one of the top Oxycon tin prescribers in the state.

Obviously a case of criminal tax evasion. Where are the IRS and Pennsylvania Dept of Revenue?

Pg 25:

Mrs. Mongar was just one of many patie nts victimized by Gosnell’s depravity. There were scores more. At least one other mother died following an abortion in which Gosnell punctured her uterus and then sent her home. He left an arm and a leg of a partially aborted fetus in the womb of anothe r woman, and then told her he did not need to see her when she became sick days la ter, having developed a temperature of 106 degrees. He perforated bowels, cervixes, and uteruses. He left women sterile.
He also killed live, viable, moving, br eathing, crying babies. He killed them by cutting their spinal cords after their mothers had delivered them after receiving excessive amounts of medication designed to induce active labor. This report documents multiple murders of viable babies. The evidence makes a compelling case that many others were also murdered.

Pg 26-27:

When Latosha Lewis began work at the clinic in 2000, the practice would perform approximately 20 first-trimester and 5 or 6 second-trimester abortions every procedure night. By 2009, however, the practice’s first-trimester abortions had dropped off significantly. Lewis explained that Gosnell had a bad reputation in the Philadelphia community, and local referral agencies would not recommend his clinic to women seeking abortions. This assertion was confirmed by representatives of Philadelphia community organizations that provide referral s and information on sexual health services.

Pg 27:

Gosnell was known as a doctor who would perform abortions at any stage, without regard for legal limits. His patients came from several states, including Delaware, Maryland, Virginia, and North Carolina, as well as from Pennsylvania cities outside the Philadelphia area, such as Allentown. He al so had many late-term Philadelphia patients because most other local clinics would not perform procedures past 20 weeks.

And how did word about Gosnell spread so far and wide?

Pg 28:

The doctor had his staff offer procedures the same day that patients walked in the door – as long as the patient paid in full, typically in cash.

Pg 29:

Sometimes, if a patient had come from out of state, the doctor would allow the woman to sleep in the facility. No personnel stayed with these patients; they were left alone and unsupervised in the clinic.
-snip-
For hours after they came to the clinic, patients were left naked from the waist down (the clinic provided no robes, only blankets that were washed once a week). Women sat in bloodstained lounge chairs in the “recovery room” while unlicensed, unsupervised workers gave them large doses of various drugs.

Pg 30-31

All afternoon and evening, as patients woke and complained of pain, workers would continue to medicate them with inject ions of sedatives. Between doses, the staff would leave patients largely untended. This would go on until the doctor arrived, some six or more hours after the patient did, or until the woman delivered. Very often, the patient delivered without Gosnell being present. Lewis testified that one or two babies fell out of patients each night. They dropped out on lounge chairs, on the floor, and often in the toilet. If the doctor was not there, it was not unusual for noone to tend to the mother or the baby. In fact , several of the clinic’s workers refused to deal with the expelled babies or the placenta . So, after delivering babies, women and girls would have to just sit and wait – sometimes on a toilet for hours – for Gosnell to arrive. Lewis acknowledged that she would not do anything but wait with the women:
A lot of times this happened when [Gosnell] wasn’t there. If . . . a baby was about to come out, I would take the woman to the bathroom, they would sit on the toilet and basically the baby would fall out and it would be in the toilet and I would be rubbing her back and trying to calm her down for two, three, four hours until Dr. Gosnell comes. She would not move.
James Johnson, who supposedly cleaned the clinic and bagged its infectious waste, confirmed Lewis’s account. He testified that sometimes patients “miscarried or whatever it was” into the toilet and clogged it. He described how he had to lift the toilet so that someone else – he said it was too disgusting for him – could get the fetuses out of the pipes.
-snip-
If fetuses had not precipitated, Gosnell would often have his staff physically push them out of their mothers by pressing on the mothers’ abdomens.

Pg 32:

Gosnell deliberately hired unqualified staff because he could pay them low wages, often in cash. Most of Gosnell’s employees who worked with patients had little or no remotely relevant training or education. Nor did they have any certifications or licenses to treat patients. Yet they did so regularly, and without supervision – in violation of Pennsylvania’s medical practice standards and the law.

Why isn't the IRS, Pennsylvania Dept of Revenue and various labor departments taking action?

Pg 34:

Ashley Baldwin was a 15-year-old high school sophomore when she started working at Gosnell’s clinic in 2006. Tina Baldwin is her mother. Although Ashley was just a teenager and still in high school, Gosnell had her assisting with procedures, performing ultrasounds, intravenously sedating patients, and assisting patients as they delivered in Gosnell’s absence.

Pg 35:

Sherry West was hired by Gosnell in October 2008. She had known Gosnell as a patient for 35 years. She had recently been diagnosed with hepatitis C. The doctor hired her to perform the same duties as his other “medical assistants.” Like them, she had no training or certificate that would qualify her to do ultrasound examinations, administer anesthesia, monitor patients in the recovery room, or do any of the other duties that she performed. No precautions were taken to protect patients from exposure to hepatitis C.

Pg 36:

Adrienne Moton knew Gosnell through his niece and spent time with his family. She worked evenings to assist with abortions, but, like the others, had no relevant training or license. She assisted with procedures and cut the spinal cords of aborted babies.

Pg 37:

Jennifer Leach is a 28-year-old woman who had a time card as if she were an employee of the clinic. She testified that Gosnell paid her $300 a week to provide “psycho-social counseling” one day a week to non-abortion patients, even though she had no training as a counselor. She acknowledged that she often did not show up to work at the clinic. Leach saw Gosnell as a patient when she was 17 years old. She said that she and Gosnell had a “fling” on and off for a couple of years, ending the week before she testified. Leach has an 11-year-old child.

Pg 39:

Gosnell routinely cracked jokes about babies whose necks he had just slit. He treated his patients with condescension – slapping them, providing abysmal care, and often refusing even to see or talk to them – unless they were Caucasian, or had money. He yelled at and intimidated his staff. And he took advantag e of poor women in desperate situations.

Where are Al Sharpton, Jessie Jackson and the rest of the race baiting crowd?

Pg 44:

The Grand Jury toured the facility at 3801 Lancaster Avenue. It is unbelievable to us that the Pennsylvania Department of Health approved this building as an abortion facility. We were stunned to learn that, between 1978 and 1993, the department sporadically inspected and approved the clinic, and then never inspected it again until February 2010, when health department employees entered the facility at the request of law enforcement officials who were investigating allegations of the illegal sale of drugs and prescriptions.

Pg 45:

According to former staff members, the facility had been substantially cleaned up by the time the Grand Jury visited it. Between late February 2010, when the practice was closed, and our tour of the clinic in August, significant efforts had been made to make the facility look and smell cleaner. Despite such efforts, it remained a wretched, filthy space. The walls appeared to be urine-splattered. The procedure tables were old and one had a ripped plastic cover. Suction tubing, which was used for abortion procedures – and doubled as the only available suction source for resuscitation – was corroded. A large, dirty fish tank stood in the waiting room, filled with turtles and fish. The dirt-floored basement was stuffed with patient files, plants, junk, and boxes of un-disposed-of medical waste. The entire facility smelled foul. These were the conditions after the facility had been shut down and cleaned. Former employees, including Latosha Lewis and Kareema Cross, testified to the abhorrent conditions when the clinic was opera ting. They described the odor that struck one immediately upon entering – a mix of smells emanating from the cloudy fish tank where the turtles were fed crushed clams and baby formula; and from boxes of medical waste that sat around for weeks at a time, leaking blood, whenever Gosnell failed to pay the bill to the disposal company.

Pg 46:

They described blood-splattered floors, and blood-stained chairs in which patients waited for and then recovered from abortions. Even the stirrups on the procedure table were often caked with dried blood that was not cleaned off between procedures. There were cat feces and hair throughout the facility, including in the two procedure rooms. Gosnell, they said, kept two cats at the facility (until one died) and let them roam freely. The cats not only defecated everywhere, they were infested with fleas. They slept on beds in the facility when patients were not using them. Kareema Cross testified about the procedure rooms: “The rooms were dirty. Blood everywhere. Dust everywhere. Nothing was clean.” The bathrooms, according to Lewis, were cleaned just once a week despite the fact that patients were vomiting in the sinks and delivering babies in the toilets.

Pg 47:

Sometimes, according to Tina Baldwin, fetal remains were left out overnight. “You knew about it the next day when you opened the door ... Because you could smell it as soon as you opened the door.” According to a plan that Gosnell filed with the Philadelphia Health Department in 2004, waste was to be stored in the basement for once-a-week pickup by a waste disposal company. But he didn’t follow the plan. He failed to pay his bills. Weeks went by without a pickup, and the containers in the basement leaked.

Pg 48-49:

The instruments that were inserted in to women’s bodies were also unsanitary, according to the workers. Kareema Cross showed the Grand Jury a photograph she had taken, showing how the instruments were pur portedly sterilized. The photo shows a pan on the floor. In it are the doctor’s tools, supposedly soaking in a sterilizing solution. But the photo shows that the instruments cannot get clean because they do not fit in the pan, and are not submerged. Gosnell would nonetheless pluck instruments from this pan on the floor and use them for procedures. Cross said that she saw Gosnell insert into a woman’s vagina a speculum that was still bloody from a previous patient. She testified about how Gosnell would ignore her complaints about his unsanitary practices:
The instruments were dirty. It was plenty of times that I had complained. He’ll – it would be a spec, a speculum and he’ll use it. I would complain – I’ll leave the speculum on his tray, so he can see it. So he can say something to whoever is cleaning them. It’ll have blood on it. And he would still use it and it was a lot of girls that was complaining about getting in fections . . . trichonomas, chlamydia because of the instruments not being cleaned.
Several workers testified that Gosnell insisted on reusing plastic curettes, the tool used to remove tissue from the uteruses, even though these were made for single use only. Latosha Lewis testified that Gosnell woul d make his staff reuse the curettes until they broke. Like Cross, Lewis believed it was the unsanitary instruments that were causing patients to become infected with chlamydia and gonorrhea.

Pg 49:

Department of Health workers found that the suction source used by the doctor to perform abortions was the only one available to resuscitate patients.

Pg 51:

Patients, meanwhile, did not receive indi vidual medical consideration. Drugs were administered without regard to a patient’ s weight, medical condition, potential risk factors, or any other relevant factors that physicians n eed to weigh in determining appropriate medication.
-snip-
Williams was known by other staff members to improvise her own drug cocktails. She would give a patient “[w]hat she thought she needed,”

Pg 52:

Gosnell’s practice of having unqualified personnel administer anesthesia began years before the death of Mrs. Mongar. We heard from a former employee, Marcella Stanley Choung, who told us that her “training” for anesthesia consisted of a 15-minute description by Gosnell and reading a chart he had posted in a cabinet. She was so uncomfortable medicating patients, she said, that she “didn’t sleep at night.” She knew that if she made even a small error, “I can kill this lady, and I’m not jail material.” One night in 2002, when she found herself alone with 15 patients, she refused Gosnell’s directives to medicate them. She made an excuse, went to her car, and drove away, never to return. Choung immediately filed a complaint with the Department of State, but the department never acted on it.

Pg 55:

An “Anesthesia for Surgery” form [Appe ndix B] presented to patients for their signature – and payment – did not identify or describe the drugs to be administered.
However, it suggested:
It will probably be best to pay the extra money and be more comfortable if some of the following conditions are true for you.

The decision to have the procedure is a difficult decision.
Medication is usually necessary for your menstrual cramps.
Your decision has been forced by your parents or partner.
Your family members or friends “don’t like pain.”

Women being forced to have an abortion. So much for a women's right to choose.

Pg 56:

Probably most dangerous of all, Gosnell’s form offered patients a choice among varying levels of pain, without any explanation of the risks presented by the various drugs or the effects of increased dosages of the drugs.

Pg 57:

Patients received multiple, heavy doses of sedatives that kept them anesthetized for several hours with no licensed medical professional on the premises. In addition to revealing the mercenary, rather than medical, nature of Gosnell’s practice, the anesthesia form confirms what Latosha Lewis and Kareema Cross told the Grand Jury: the “custom” medication administer ed to second-trimester patients was not just a single dose that was administered to keep the patients asleep through a surgical procedure of limited duration. Rather, the medication was first “inserted prior to the procedure” and sedation was “repeatedly administered” until the procedure was completed.

Pg 59:

Women were then placed in the “recovery room” where any one of the several unlicensed workers placed an IV access in the women’s hands. For the next several hours – sometimes as many as eight or nine – women sat, medicated and in labor until either the doctor, or their baby, arrived. Lewis testified: We would undress them even tually from waist down, cover them up, and just put a blanket over them and they would sit there for hours while we’re – either every hour on the hour or whenever we got a chance, we’re still giving them more Cytotec. If the IV is in, we’re giving them pain meds through the IVs. And that’s what we’re doing the whole time until the doctor arrives, unless the baby comes out.

Pg 60:

Gosnell used medication – and slaps – to silence loud or complaining patients.

Pg 61:

Even when Gosnell was in the building, he did not oversee the administration of anesthesia – except when the patient was white. Tina Baldwin told the Grand Jury that the untrained medical assistants, without supervision by Gosnell, routinely administered even the final dose of sedation just before the procedure – unless the patient was white.

Pg 62:

Q: Okay. Was he present when you did that medication?
A: No, no. And sometimes he asked them – but it was a race thing.
Q: What do you mean?
A: It was – he sometimes he used to – okay. Like if a girl – the black population was – African population was big here. So he didn’t mind you medicating your African American girls, your Indian girl, but if you had a white girl from the suburbs, oh, you better not medicate her. You better wait until he go in and talk to her first. And one day I said something to him and he was like, that’s the way of the world. Huh? And he brushed it off and that was it.
Tina Baldwin also testified that white patients often did not have to wait in the same dirty rooms as black and Asian clients. Instead, Gosnell would escort them up the back steps to the only clean office – Dr. O’Neill’s – and he would turn on the TV for them. Mrs. Mongar, she said, would have been treated “no different from the rest of the Africans and Asians.”

Where are Al Sharpton, Jessie Jackson and the rest of the race baiters?

Pg 62:

Gosnell employed a high school student to medicate and monitor abortion patients until he and other staff arrived at the clinic to perform abortions.

Pg 63-64:

Ashley testified:
I was just supposed to be in the recovery room, and inside another small room. But since they weren’t there, I had to bring the girls from the front to the back, set them up in both rooms, wait until he got there, if a precipitation happened, I had to handle it on my own.
By “precipitation,” Ashley meant that women and girls actually delivered babies. They delivered babies when Ashley was the only person present in the clinic to take care of them, their babies, the placenta, and all of the other drugged patients waiting for procedures.

Pg 64:

Other staff members confirmed that it was standard procedure for women to deliver fetuses – and viable babies – into toilets while patients and staff waited for Gosnell to arrive at the clinic.

Pg 67:

Ashley was working 50 hours a week at the clinic and Gosnell was paying her $8.50 an hour – in cash. On her high school “work roster,” Gosnell wrote that she worked from noon to 6:00 p.m. Her title was “student.” In truth, Ashley often worked until 2:00 a.m. and performed the duties of a registered nurse or a doctor. When asked who was in charge of the clinic before Gosne ll arrived, Ashley testified: “Me.”

Pg 67:

According to Lewis, Gosnell hired Sherry West when she lost her job at the Philadelphia Veterans Administration Medical Center after contracting hepatitis C. Yet, despite her hepatitis, West regularly failed to wear gloves when treating patients.

Pg 69:

Cross testified that she could recall at least 15 times when she had medicated a second-trimester patient only to have Williams come along right behind her and medicate again. Lewis said that no one, including herself, recorded the repeat ed doses of sedation that the clinic’s staff administered to second-trimester patients to keep them anesthetized throughout their – often six- or seven-hour – wait for the doctor.

Pg 71-73:

Gosnell called an ambulance only after the cousins demanded that he do so. Kareema Cross testified that, after having problems performing Ms. Haynes’s abortion and extracting only portions of her fetus, Gosnell had placed her in the recovery room while he performed abortions on other patients. Rather than call an ambulance, Gosnell kept Ms. Haynes waiting for hours after the unsuccessful procedure because he wanted to try to fix it himself.
By the time Ms. Haynes’s cousins rescued her from the recovery room, Gosnell had tried at least twice, unsuccessfully, to complete the abortion. Ms. Haynes was transported to the Hospital of the University of Pennsylvania. There, doctors discovered that Gosnell had left most of the fetus inside her uterus and had perforated her cervix and bowel.
Ms. Haynes required surgery to remove five inches of bowel, needed a large blood transfusion, and remained hospitalized for five days. Similarly, Gosnell should have sent another patient, Marie Smith, to the hospital when he was unable to remove the entire fetus during her abortion in November 1999. But again, he just kept the patient waiting, sedated and bleeding in the recovery room while he proceeded with other patients.
Again, it was an insistent relative – Marie’s mother – who found her. In Marie Smith’s case, Gosnell did not tell her that he had left parts of the fetus inside her uterus. (Doctors are required to inspect the extracted tissue to ensure they have removed it all.) Instead, Gosnell allowed Marie Smith to go home.
When her mother called days later to report that Marie’s condition had worsened, he assured her that Marie would be fine. Fortunately, the mother ignored Gosnell’s assurances and took her daughter to the emergency room. When they arrived at Pres byterian Hospital, Marie was unconscious.
Doctors found that Gosnell had left fetal parts inside her and that she had a severe infection. They told her she was lucky to be alive. Another patient, a 19-year-old, had to have a hysterectomy after Gosnell left her sitting in his recovery room for over four hours after perforating her uterus. Gosnell finished performing the abortion at 8:45 p.m. on April 16, 1996, but did not call fire rescue until 1:15 a.m. By the time emergency help arrived, the patient was not breathing. She arrived at the Hospital of the University of Pennsylvania in shock, having lost significant blood. To save her life, doctors had to remove her uterus.
In at least one case, Gosnell prevented a patient’s companion from summoning help. The patient, a recovering addict who was undergoing methadone treatment, started convulsing when Gosnell administered anesthesia. When she fell off the procedure table and hit her head, the staff summoned her companion who was waiting for her. The companion asked Gosnell to call an ambulance, but Gosnell refused. He also prevented the companion from leaving the clinic to summon help.
Tina Baldwin told us that she knew of two or three times that Gosnell perforated a woman’s uterus and then tried to surgically repair these mistakes himself. According to Tina Baldwin, Gosnell did not even tell these patients that he had harmed them.

Pg 73:

Gosnell engaged in other practices with patients that defy any medical or even common-sense explanation. Steven Massof testified that the doctor would often photograph women’s genitalia before he performed their abortions.

Pg 74:

Another of the doctor’s practices that defies explanation was his habit of cutting the feet off of aborted fetuses and saving them in specimen jars in the clinic. Kareema Cross showed the Grand Jury photographs she had taken in 2008 of a closet where Gosnell stored jars containing severed feet. During the February 2010 raid, investigators were shocked to see a row of jars on a clinic shelf containing fetal parts.

Pg 76:

According to Kareema Cross, the clinic owned one old electrocardiogram (EKG) machine to monitor heart rate and a pulse oximeter, an instrument that is attached to the patient’s finger and measures oxygen saturation in the blood, but these had not worked for at least six years.

Pg 76:

From 2006 until the clinic closed in 2010, Gosnell’s recovery room was often supervis ed – and not constantly, because she had several other duties – by a high school student , Ashley Baldwin. The state Department of Health documents that, as far back as 1989, Gosnell had no registered or licensed nurses to staff the clinic’s recovery room.

Pg 79:

Gosnell performed at least four or five illegal abortions every week. When a detective asked the doctor what percentage of the fetuses – including the first- and second-trimester fetuses – found at the facility during the February 2010 raid were beyond 24 weeks, Gosnell himself estimated “ten or twenty percent at the most.”

Pg 79:

Gosnell’s former employees testified that they knew many abortions were performed beyond 24 weeks because they had performed ultrasounds that established gestational ages greater than the 24-week legal limit.
When this happened, they would tell Gosnell, and he would often redo the ultrasound, or staff members would be ordered to do so, to produce a different gestational age to record in the patient’s file.
Gosnell taught his employees how to manipulate the ultrasound machine to get a false reading – one that would make the fetus appear to be smaller, and younger, than it actually was.

Pg 81:

If their photos showed a biparietal diameter, a measurement of the fetus’s skull, corresponding to a gestational age above 24 weeks, Gosnell simply substituted a different photo showing a measurement consistent with a younger fetus. Ashley Baldwin testified that she saw Gosnell manipulate ultrasound results himself “a good ten times.”

Pg 81-82:

Lewis and Massof both testified that they believed Gosnell dealt with some of the patients with the longest-term pregnancies on Sundays, when his staff was not at the clinic. When Massof came in on Monday mornings he would find bloody instruments in the sink even though they had all been cleaned before the facility closed on Saturday night. When Massof asked Gosnell if he had seen patients on Sunday, the doctor answered, according to Massof: “Oh, yes, I took care of it. I had my wife or somebody help me or whatever.” Gosnell’s wife Pearl confirmed that she assisted her husband with procedures on Sundays.

Pg 83:

The Grand Jury, reviewing just the fracti on of Gosnell’s abortion files seized by authorities, was still able to document numerous instances in which ultrasound readings were manipulated to disguise illegal late -term abortions

Pg 83:

Clinic staff testified that Gosnell took patients files home and did not keep records of most of his late-term abortions at the clinic. Tina Baldwin explained that Gosnell took second-trimester files home “if there were difficult cases or some cases where he thought they shouldn’t be in there.” Massof told us that Gosnell always took files home, so “I think he has them. If he hasn’t destroyed them, he has them.” A subsequent search of Gosnell’s home and car turned up only some of these files. One of the files seized from Gosnell’s car was partially shredded.

Pg 84:

The vast majority of Gosnell’s post-24-week abortions we learned of from files. But there were some that came to the attention of other doctors and hospitals that were called on to treat his patients. This is how the Grand Jury learned of one third-trimester viable fetus that Gosnell caused to die be fore it was born. He did so by initiating an abortion on a 14-year-old girl who is estimat ed to have been 30 weeks pregnant. The teenager came to Gosnell for an abortion in September 2007.

A 14 year old getting an abortion. Shouldn't a pregnant 14 year old be below the age of consent and therefore automatically a statutory rape victim? Why don't abortion clinics notify authorities of statutory rape?

Pg 86:

the medical examiner reported Gosnell’s violations of the Abortion Control Act to the Pennsylvania Department of Health. It took no action.

Pg 86:

Gosnell began an abortion on a 29-week pregnant woman and then refused to take dilators out when the woman changed her mind.

Pg 88:

This amounts to nearly $1.8 million a year – almost all of it in cash – assuming just three procedure nights a week. (Testimony indicated that he performed abortions from about 8:00 p.m. to 1:00 a.m., three nights a week – for a total of 15 hours.) In light of the testimony we heard that Gosnell performed the really late third- trimester abortions on Sundays, his take was likely much higher. And none of this includes his income from writing prescriptions – according to one law enforcement agent, Gosnell was one of the top three Oxycontin prescribers in the state of Pennsylvania.

Pg 89:

Gosnell also defrauded insurance companies.

And what action is being taken against him by the Pennsylvania Insurance Commission?

Pg 89:

Gosnell defrauded the Delaware Pro-Choice Medical Fund as well

Interstate crime. Where are the Fed's?

Pg 90:

A national association of ab ortion providers declined to admit the Women’s Medical Society as a member, finding it to be the worst facility its inspector had ever seen.

And the NAB took no further action against Gosnell.

Pg 96:

Gosnell’s contemptuous disregard for the health, safety, and dignity of his patients continued for 40 years.
Gosnell’s disregard for his patients’ safety was nothing new. The Pennsylvania Department of Health has records as far back as the 1980s documenting Gosnell’s dangerous practices. For decades, Gosnell did not staff his facility with licensed or qualified employees. He never properly monitored women under sedation. He botched surgeries and then failed to summon emergency help when it was needed.
His entire practice showed nothing but a callous disdain for the lives of his patients. As far back as 1972, he was notorious for his mistreatment of the women who came to him for treatment.

Pg 98:

The Penns ylvania Board of Medicine ignored his role in this grotesquely unsuccessful experiment, which seriously and permanently maimed several women. The Board overlooked Gosnell’s unprofessional conduct not only in the 1970s but for the next three decades, as he continued to employ unlicensed workers to practice medicine at his clinic, and as his patients con tinued to suffer serious injuries or worse during abortion procedures.

Pg 99-100:

Gosnell’s staff testified about scores of gruesome killings of such born-alive infants carried out mainly by Gosnell, but also by employees Steve Massof, Lynda Williams, and Adrienne Moton. These killings became so routine that no one could put an exact number on them. They were consider ed “standard procedure.” Yet some of the
slaughtered were so fully formed, so much like babies that should be dressed and taken home, that even clinic employees who were accustomed to the practice were shocked.

Pg 101:

After the baby was expelled, Cross noticed that he was breathing, though not for long. After about 10 to 20 seconds, while the mother was asleep, “the do ctor just slit the neck,” said Cross. Gosnell put the boy’s body in a shoebox. Cross described the baby as so big that his feet and arms hung out over the sides of the container. Cross said that she saw the baby move after his neck was cut, and after the doctor placed it in the shoebox.

Pg 103:

Ashley Baldwin remembered Gosnell severing the neck of a baby that cried after being born. The baby had “precipitated” when the doctor was not in the clinic. Lynda Williams placed the baby in a basin on the counter where the instruments were washed and called the doctor to come.
Ashley heard the infant cry. She saw the baby move while it was on the counter. She estimated the infant was at least 12 inch es long. When Gosnell arrived at the clinic, she recalled, “he snipped the neck, and said there is nothing to worry about,

Pg 103:

If Gosnell was absent, his employees would kill viable babies. Ashley Baldwin saw Steve Massof slit the necks of babies that moved or breathed “five or ten” times. Massof, repeating what he had been taught by Gosnell,

Pg 104:

Kareema Cross testified th at, between 2005 and 2008, she saw Steve Massof sever the spinal cords of at least ten babies who were breathing and about five that were moving.

Pg 104:

When Massof left the clinic in 2008, Lynda Williams took over the job of cutting baby’s necks when Gosnell was not there. Cross saw Williams slit the neck of a baby (“Baby C”) who had been moving and breathing for approximately twenty minutes. Gosnell had delivered the baby and put it on a counter while he suctioned the placenta from the mother. Williams called Cross over to look at the baby because it was breathing and moving its arms when Williams pulled on them. After playing with the baby, Williams slit its neck.

Pg 104-105:

Adrienne Moton also killed at least one baby by cutting its spinal cord. Cross testified that a woman had delivered a large baby into the toilet before Gosnell arrived at work for the night. Cross said that the baby was moving and looked like it was swimming. Moton reached into the toilet, got the baby out and cut its neck. Cross said the baby was between 10 and 15 inches long and had a head the size of a “big pancake.” Gosnell later measured one of the baby’s feet and said that it was 24.5 weeks.

Pg 105:

Killing really had to be part of Gosnell’s plan. His method for performing late- term abortions was to induce labor and delivery of intact fetu ses, and he specialized in patients who were well beyond 24 weeks. Thus, the birth of live, viable babies was a natural and predictable consequence. The subsequent slitting of spinal cords, without any consideration for the babies’ viability, was an integral part of what Gosnell’s employees called his “standard procedure.”

Pg 108:

Gosnell severed spinal cords and suctioned and crushed skulls after the babies were fully delivered.

Pg 111:

Kareema Cross testified that when she first started working at the clinic, in 2005, Gosnell slit the neck of every baby.

Pg 112:

Gosnell and his staff regularly cut necks of viable babies after observing signs of life.

Pg 114:

Ashley Baldwin also saw Gosnell slice the neck of moving and breathing babies. When asked how many times Ashley had observed babies being delivered that were moving or breathing or crying and the doctor cut the neck, she answered: “Most of the second tris that were over 20 weeks.” She said this happened probably dozens of times, maybe more. She described at least 10 babies as big enough to buy clothes for, to dress, and to take care of. She told the Grand Jury what happened to them:
Q. And what happened to those ten babies that came out from their mother, that were big enough that you could put clothes on and take home and take care of, that moved around, what did you see happen to them?
A. He killed them.
Q. Who killed them?
A. Doc.

Pg 114:

Tina Baldwin told the jurors that Gosnell once joked about a baby that was writhing as he cut its neck: “that’s what you call a chicken with its head cut off.”

Pg 114:

Although Massof was not as cavalier about what he did, he admitted that there were about 100 instances in which he severed the spinal cord after seeing a breath or some sign of life:

Pg 115:

We believe, given the manner in which Gosnell operated, that he killed the vast majority of babies that he aborted after 24 weeks. We cannot, however, recommend murder charges for all of these cases. In order to constitute murder, the act must involve a baby who was born alive. Because files were falsified or removed from the facility and possibly destroyed, we cannot substantiate all of the individual cases in which charges might otherwise have resulted.

Pg 117:

Karnamaya Mongar died because Gosnell’s unlicensed employees excessively drugged her.

Pg 121:

Repeated injections of strong narcotics, administered in accordance with Gosnell’s standard procedures, killed Mrs. Mongar.

Pg 137:

The callous killing of babies outside the womb, the routinely performed third-trimester abortions, the deaths of at least two patients, and the grievous health risks inflicted on countless other women by Gosnell and his unlicensed staff are not the only shocking things that this Grand Jury investigation uncovered. What surprised the jurors even more is the official neglect that allowed these crimes and conditions to persist for years in a Philadelphia medical facility.

Pg 137:

We discovered that Pennsylvania’s Depart ment of Health has deliberately chosen not to enforce laws that should afford patient s at abortion clinics the same safeguards and assurances of quality health care as patients of other medical service providers. Even nail salons in Pennsylvania are monitored more closely for client safety.

Pg 138:

State health officials knew that Gosnell and his clinic were offering unacceptable medical care to women and girls, yet DOH failed to take any action to stop the atrocities documented by this Grand Jury. These official s were far more protective of themselves when they testified before the Grand Jury. Even DOH lawyers, including the chief counsel, brought private attorneys with them – presumably at government expense.

Pg 138:

Gosnell’s clinic – with its untrained staff, its unsanitary conditions and practices, its perilously lax anesthesia protocols, its willingness to perform late-term abortions for exorbitant amounts of cash, and its routine procedure of killing babies after they were delivered by their unconscious mothers – offers a telling example of how horrendous a Pennsylvania facility can be and still operate with DOH “approval.”

Pg 139:

One significant finding in the 1979 evaluation was that there was adequate access for a stretcher, something that proved not to be the case when EMTs needed to transport Karnamaya Mongar from the facility in November 2009.

Pg 140:

Even though the first DOH Certificate of Approval for Gosnell’s clinic expired on December 20, 1980, the next documented site review was not conducted until August 1989.

Pg 140:

By 1989, Gosnell, who is not board-certified as either an obstetrician or a gynecologist, was the only doctor at the facility. The DOH site reviewers also noted that there were no nurses working at the clinic . Blood work was no longer sent out to an independent lab, but was done, supposedly, by “medical assistants.” And in 7 of the 30 patient files reviewed, there was no lab work recorded. The evaluators noted several violations of Pennsylvania abortion regulations, including: no board-certified doctor on staff or contracted as a consultant; no nurses overseeing the recovery of patients; no transfer agreement with a hospital for emergency care; and no lab work recorded in several files. Even so, based on mere promises to improve documentation and filing, and to hire nurses, the DOH site reviewers recommended approval of Gosnell's clinic for another 12 months.

Pg 140:

Two and a half years later, in March 1992, when DOH representatives next inspected the clinic, there were still no nurses to monitor patient recovery. Evaluators Janice Staloski and Sara Telencio noted that Gosnell was still the only doctor (a Dr. Martin Weisberg was listed as a consultant); that the facility employed no nurses; and that medical assistants were doing lab work. They did indicate there was adequate access for stretchers and wheelchairs

Pg 141:

The next inspection was conducted on April 8, 1993, by DOH evaluators Susan Mitchell and Georgette Freed-Wolf. This was also the last site review – until February 2010, when an inspection occurred because law enforcement executed search warrants for illegal drug activity.

Pg 142-143:

During the next 16 plus years – as Gosnell collected fetuses’ feet in jars in his office and allowed medical waste to pile up in the basement; as he replaced his few licensed medical assistants with untrained workers and a high school student; as his outdated equipment rusted and broke and he routinely reused instruments designed for single-use; as he allowed unqualified staff to administer an esthesia and to deal with babies born before he arrived at work for the day; and as he caused the deaths of at least two patients while continuing to perform illegal third-trimester abortions and to kill babies outside their mothers’ wombs – DOH never conducted another on-site inspection at the Lancaster Avenue facility.

Pg 143:

The state Department of Health failed to investigate Gosnell’s clinic even in response to complaints. According to DOH witnesses, sometime after 1993, DOH instituted a policy of inspecting abortion clinics only when there was a complaint. In fact, as this Grand Jury’s investigation makes clear, the department did not even do that.

Pg 144:

We are very troubled that state health officials ignored this respected physician’s report that girls were becoming infected with sexually transmitted diseases at Gosnell’s clinic when they had abortions there. If Dr. Schwarz’s complaint did not trigger an inspection, we are convinced that none would.

Pg 144:

We also do not understand how a report of this magnitude was not at least added to Gosnell’s file at the state department of health. It suggest s to us that there may have been many more complaints that were never turned over to the Grand Jury.

Pg 144:

We heard testimony from DOH officials who should have been aware of Dr. Schwarz’s complaint – Kenneth Brody and Janice Staloski, at the least. Yet they made no mention of it to the Grand Jury. Did they remember the complaint and choose to exclude it from their testimony? Is ignoring complaints of this seriousness so routine at DOH that they honestly do not remember it? Or did the secretary of health never even forward it on for action?

Pg 147:

Brody confirmed some of what Staloski told the Grand Jury. He described a meeting of high-level government officials in 1999 at which a decision was made not to accept a recommendation to reinstitute regular inspections of abortion clinics. The reasoning, as Brody recalled, was: “there was a concern that if they did routine inspections, that they may find a lot of these facilities didn’t meet [the standards for getting patients out by stretcher or wheelchair in an emergency], and then there would be less abortion facilities, less access to women to have an abortion.”

Pg 148:

Whatever its motivation, DOH’s deliberate policy decision not to conduct regular inspections of abortion clinic s did not serve the women of this Commonwealth. Nor did it protect late-term fetuses or viable babies born alive.

Pg 149:

Without regular inspections, providers like Gosnell continue to operate; unlawful and dangerous third-trimester abortions go undetected; and many women, especially poor women, suffer. These are all consequences of DOH’s abdication of its responsibility.

Pg 149:

if Staloski was instructed not to conduct regular, annual inspections, that does not explain why she failed to order inspections when complaints were received . It is clear to us that she was made aware, numerous times, that serious incidents had occurred at Gosnell’s clinic. These incidents, which evidenced alarming as well as illegal long-standing patterns of behavior, warranted investigation. Yet, in all the years she worked at the department, Staloski never ordered even one inspection.

Pg 149:

Not even Karnamaya Mongar’s death triggered an inspection or investigation.

Pg 150:

Boyne blamed Staloski. She said that her boss told her that DOH did not have the authority to investigate Mrs. Mongar’s death. Staloski apparently reached this decision on her own, without ever consulting Brody, the legal counsel.

Pg 151:

Appallingly, the chief counsel for the department of health, Christine Dutton, defended Staloski’s inaction following Mrs. Mongar’s death. Dutton testified that she had reviewed the emails and documents showing that Staloski and her staff were communicating with Gosnell’s office to get him to file the MCARE form. Based on these very minimal efforts, Dutton insisted: “we were responsive.”

Pg 151:

Pushed as to whether the death of a woman following an abortion should have prompted more action – perhaps an investigation or a report to law enforcement – Dutton argued there was no reason to think the death was suspicious. “People die,” she said.

Pg 151:

Not only was a probe into Mrs. Mongar’s death authorized and appropriate under the Abortion Control Act, it was required under the MCARE law. 40 P.S. §306. Yet DOH did not investigate.

Pg 151:

Bureau Director Staloski, in fact, readily acknowledged many deficiencies in DOH’s, and her own, oversight of abortion facilities. But her dismissive demeanor indicated to us that she did not really understand – or care about – the devastating impact that the department’s neglect had had on the women whom Gosnell treated in his filthy, dangerous clinic.

Pg 152:

When DOH inspectors finally entered Gosnell’s clinic in February 2010, not at Staloski’s direction but at the urging of law enforcement, Staloski seemed more annoyed than appalled or embarrassed

Pg 152:

On the morning after the raid, she received a copy of an email that Boyne wrote to Brody the night of the raid. Boyne reported to the department’s senior counsel that, at 12:45 a.m., she had told the Department of Health staff members at the clinic to “wrap it up and secure lodging in the interest of their safety.” Boyne told Brody that the “staff walked into a very difficult setup.” She complained that a representative of the District Attorney’s Office was “badgering” DOH staff to shut down the facility immediately. Boyne was seeking Brody’s legal guidance. Staloski’s response to Boyne’s email was: “I’d say we were used.” Boyne’s reply: “Bingo.”

Pg 157:

The state Department of Health monitors other comparable health care facilities to assure quality care. The Department of Health’s decades-long neglect of its duty to ensure the health and safety of women undergoing medical procedures in abortion clinics is in stark contrast to its policies and practices with respect to procedures performed in other types of health care facilities.

Pg 160:

The state Department of Health inexplicably allows abortion clinics, alone, to go unmonitored. The Grand Jury asked several DOH employees, attorneys as well as those charged with overseeing abortion facilities, why the department does not treat abortion clinics as ASFs when the language of the Health Care Facilities Acts is so clear. Their unsatisfactory answers left us bewildered.

Pg 166:

Pennsylvania’s abortion regulations, written by the Department of Health, are totally inadequate to protect the health and safety of women at abortion clinics. The abhorrent conditions and practices inside Gosnell’s clinic are directly attributable to the Pennsylvania Health Department’s refusal to treat abortion clinics as ambulatory surgical facilities.

Pg 167:

Most importantly, the abortion regulations include no requirement for DOH ever to inspect or monitor abortion providers. The Grand Jury was astonished to discover that abortion clinics in Pennsylvania, unlike any other health care facility, are apparently supposed to operate on the honor system.

Pg 169:

Assuring safety at abortion clinics has been a low priority for Pennsylvania’s Department of Health for decades. No one from DOH was able to tell us who decided to exclude abortion clinics from meaningful oversight that would protect patient safety, or why such a decision was made. Nor did the jurors get a satisfactory an swer as to why abortion clinics are under DOH’s Division of Home Health (which oversees agencies that provide care in people’s houses), rather than the more appropriate Division of Acute and Ambulatory Care. Or why, on DOH’s website, even on the page that lists the types of facilities overseen by the Division of Home Health, abortion clinics are not even mentioned.

Pg 171:

State Department of Health inspectors refused to share information with law enforcement. Darlene Augustine testified that she was instructed by senior attorneys for DOH, Kenneth Brody and James Steele, that she should not reveal anything about Karnamaya Mongar’s death to law enforcement when she accompanied them on the raid in February 2010.

Pg 173:

PENNSYLVANIA’S DEPARTMENT OF STATE NEGLECTED ITS DUTY TO DISCIPLINE A DOCTOR ENGAGE D IN UNPROFESSIONAL CONDUCT. The Department of Health was not the only state agency that could and should have shut down Gosnell decades ago.

Pg 174:

Pennsylvania Department of State attorneys failed to investigate a 22-year-old patient’s death caused by Gosnell’s recklessness. In all this inaction, one failure to investigate stands out. On October 9, 2002, the Professional Underwriters Liability Insurance Company reported to the State Board of Medicine that it had paid a $400,000 settlement to the family of Semika Shaw, the 22- year-old mother of two who died following an abortion procedure at Gosnell’s clinic in March 2000.

Pg 176:

Before Department of State prosecutors decided not to investigate the 22-year-old patient’s death, they had been told of Gosnell’s many illegal practices. What makes these prosecutors’ inaction even more astonishing is that they did know more than the bare facts included in the Board attorney’s evaluation of the case.

Pg 181:

Other Department of State prosecutors also failed to act against Gosnell.

Pg 184:

In 2009, another Department of State prosecutor closed – without any investigation – a complaint that Gosnell acted recklessly in perforating another woman’s uterus, cervix, and bowel.

Pg 190:

The problems with the Board of Medicine and Department of State go beyond individual prosecuting attorneys. The Grand Jury is convinced – based on the number of state prosecutors who failed to take action against Gosnell, on the fact that the prosecutors’ supervisors uniformly approved recommendations not to take action

Pg 192:

The Department of State only pursued allegations aggressively when the case was very public, or when the complainant knew somebody. Given the inaction by Pennsylvania Department of State attorneys on seven of the eight recorded complaints against Gosnell, the Grand Jury questions how aggressively the prosecutors are protecting the public from bad doctors. The complaints relating to Gosnell’s abortion practice were serious, the harm he inflicted on patients was substantial, and his routine included the wanton killing of babies outside the womb. Yet even a 22-year-old woman’s death did not warrant an investigation, according to the Board of Medicine

Pg 196:

Patients and groups that were aware of Gosnell’s reckless practices found it hard to file complaints with the state.

Pg 197:

A Department of State witness complained that the department does not have more law enforcement powers, but failed to use the ones that it has.

Pg 199:

THE PHILADEPHIA DEPARTMENT OF PUBLIC HEALTH ALSO IGNORED ALARMING WARNINGS ABOUT GOSNELL’S PRACTICE.

Pg 199:

Supervisors in the Division of Disease Control ignored a nurse’s disturbing report about conditions in Gosnell’s clinic in 2008 and 2009.

Pg 204:

The Philadelphia Health Department’s Environmental Engineering Section failed to follow through after receiving a complaint in 2003 about aborted fetuses stored in an employee refrigerator.

Pg 212:

FELLOW DOCTORS WHO OBSERVED THE RESULTS OF GOSNELL’S RECKLESS AND CRIMINAL PRACTICES FAILED TO REPORT HIM TO AUTHORITIES. Pennsylvania’s Abortion Control Act requires any doctor who treats a woman because of a complication arising from an abortion to make a report to DOH. Willful failure to do so constitutes “unprofessional conduct” and subjects the treating doctor to sanctions by the Board of Medicine. Clearly, this law is being violated, if not willfully, at least consistently.

Pg 219:

After reviewing extensive and compelling evidence of criminal wrongdoing at the clinic, the Grand Jury has issued a presentment recommending the prosecution of Gosnell and members of his staff for criminal offenses including:

Murder of Karnamaya Mongar
Murders of babies born alive
Infanticide
Violations of the Controlled Substances Act
Hindering, Obstruction, and Tampering
Perjury
Illegal late-term abortions
Violations of the Abortion Control Act
Violations of the Controlled Substances Act
Abuse of Corpse
Theft by Deception
Conspiracy
Corrupt Organization
Corruption of Minors

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