PHILADELPHIA - Regulators ignored report after report of horrific conditions at a squalid abortion clinic, prosecutors said, leaving a trail of missed chances over the years to stop a doctor from performing illegal, late-term abortions that killed at least two patients and hundreds of newborns.
The officials' failure to follow up on complaints against Dr. Kermit Gosnell came amid a "live and let die" political climate that effectively ended inspections of all abortion clinics in Pennsylvania, according to the grand jury that indicted Gosnell.
Gosnell, 69 - a family practice physician not certified to perform abortions - was arraigned Thursday on charges of murdering seven babies and one patient. The indictment against him detailed a gruesome litany of failures and refusals to uphold even the most basic public health guidelines.
Authorities allege that Gosnell and a fleet of undertrained - sometimes untrained - workers ran a ghoulish operation in Philadelphia in which labor was induced in very late-term pregnancies with unsanitary equipment, the viable babies born alive and killed with scissors to the spine, and their body parts left in jars - or clogging plumbing into which unattended women had given birth.
Nearly a decade ago, according to legal documents, a former Gosnell employee gave the state's Board of Medicine 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."
Nothing was done.
In its report, the grand jury said failures of the Pennsylvania Department of Health and other agencies - including the Department of State, under which the Board of Medicine falls - allowed the clinic to operate nearly unimpeded since the late '70s. It hadn't been inspected since 1993 and wasn't closed until it was finally raided as part of a drug bust early last year.
"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," the grand jury wrote.
A spokeswoman for Republican Gov. Tom Corbett, who was inaugurated this week, said Thursday that Corbett held a morning meeting about the matter with his new nominees for secretaries of health and state.
"He called it horrific, and certainly public safety is one of his major concerns," said administration spokeswoman Janet Kelley. Officials are reviewing the grand jury report and working on a response, she said.
"It's essentially looking at information gathering and certainly changing things for the better," she said.
The Health Department has not commented despite repeated requests from The Associated Press. Lawyer William J. Brennan, who represented Gosnell during the investigation, has declined to comment.
Former Health Department official Janice Staloski personally inspected the clinic in 1992, but "let Gosnell slide on the violations that were already evident then," the grand jury said. A decade later, when she headed the division that was supposed to regulate abortion providers, Staloski failed to order an investigation of the clinic despite having received several complaints about Gosnell, the report said.
Staloski, who retired last year, declined to comment Thursday. Her lawyer, Arthur Donato, said Staloski acknowledged to the grand jury that she made mistakes.
"I think the grand jury report speaks to an institutional and systemic problem, and I think a lot of people were responsible for the fact that these clinics were not surveyed annually," he said. "She did receive some complaints (about Gosnell) and she did not cause a survey or an inspection to occur, and I think she testified truthfully that she should have."
Senate Majority Leader Dominic Pileggi, R-Delaware, called the allegations "monstrous and appalling" and said the Legislature would convene hearings relatively soon to investigate how state agencies mishandled complaints about Gosnell and the clinic.
Complaints about Gosnell to state regulators went nowhere, even though 46 lawsuits - including one over the death of a 22-year-old woman in 2000 - had been filed against him.
In its report, the grand jury said the department's chief counsel, Christine Dutton, defended the department's indifference. "People die," she said.
The grand jury's 261-page report several missed or ignored opportunities to close the clinic over the years, including:
- a doctor from Children's Hospital of Philadelphia who complained about patients contracting venereal diseases after Gosnell abortions.
- a medical examiner in suburban Delaware County who told the Health Department that Gosnell had performed an illegal abortion on a 14-year-old girl carrying a 30-week-old fetus. Abortions after 24 weeks, or about six months, are illegal in Pennsylvania.
- the Health Department being told of the November 2009 death of Karnamaya Mongar, a 41-year-old refugee from Nepal who perished at the clinic after being given too much Demerol and other drugs.
Gosnell earned his medical degree from Thomas Jefferson University in Philadelphia and is board certified in family practice. He started, but did not finish, a residency in obstetrics-gynecology, authorities said.
The State Health Department first gave the clinic, the Women's Medical Society, a one-year license when it opened in 1979, when a certified ob-gyn and nurses were listed as employees. The state approval expired in 1980, but the next site review did not come until 1989.
By then, Gosnell was the only doctor on site, and the clinic had no nurses and no outside lab work being done, the grand jury report says. Promises were made to improve the failings, and the state renewed its approval.
In 1992, a visit showed there were still no nurses or ob-gyn, and nothing suggests the state inspectors checked any patient files, the report says. Inspectors left blank the sections on who was providing anesthesia and post-operative care. They concluded "no deficiencies."
The final inspection came in April 1993, four years after Gosnell had promised to hire nurses. There were none in the recovery room, according to the report. The state cited Gosnell for expired medications and missing lab work but said the problems had been remedied - though there was no follow-up inspection - three months later.
The state's reluctance to investigate through several administrations may stem partly from the political sensitivity of the abortion debate, Philadelphia District Attorney Seth Williams said.
The office of former Gov. Ed Rendell, the Democrat who preceded Corbett, said he was traveling and couldn't be reached for comment to The Associated Press. Republican former Gov. Tom Ridge did not respond to a request for comment.
Most doctors won't perform abortions after 20 weeks because of the risks. Authorities say Gosnell's clients paid $325 for first-trimester abortions and $1,600 to $3,000 for abortions up to 30 weeks.
In a typical late-term abortion, the fetus is dismembered in the uterus and then removed in pieces. That is more common than the procedure opponents call "partial-birth abortion," in which the fetus is partially extracted before being destroyed.
The grand jury's report notes that hundreds of babies were probably killed over the years - but elapsed time and destroyed records are preventing a larger prosecution.
The grand jury charged Gosnell with the death of only one patient, Mongar. But its report details the death, years earlier, of a 22-year-old woman whose uterus Gosnell perforated during an abortion, prosecutors said. After she died of sepsis, Gosnell settled a civil suit for nearly $1 million. His insurance company forwarded details to the state Board of Medicine, but "department attorneys dismissed this complaint, too," the report said.
Nine clinic employees are charged besides Gosnell. Four of them are charged with murder, and five others were charged with conspiracy, drug and other crimes. All were arraigned Thursday along with Gosnell.