'Official Neglect' Allowed Abortion Doctor to 'Butcher'

January 28, 2011

January 28, 2011 — A "complete regulatory collapse" allowed Philadelphia physician Kermit Gosnell, MD, to illegally abort third-trimester fetuses, sever the spinal cords of babies aborted alive with scissors, and leave a trail of injured and dead female patients in his wake over several decades, according to a grand jury report on a case that has shocked the nation.

The Pennsylvania grand jury, which released its findings last week, said it was shocked not only by the medical "mayhem" of Dr. Gosnell but also by a pattern of "official neglect" that extended from the state medical board to physicians at Philadelphia hospitals who treated his patients for perforated bowels and uteruses. Plenty of agencies and individuals saw numerous signs of something gone terribly wrong but failed to intervene.

"Had state and local officials performed their duties properly, Dr. Gosnell's clinic would have been shut down decades ago," the report stated.

Dr. Kermit Gosnell. Photo courtesy of Philadelphia District Attorney's office

Instead, the horrors of the clinic — including its jars of fetal feet and other fetal parts stored in freezers — were accidently discovered and ended early last year after federal agents conducted a raid based on reports of Dr. Gosnell illegally prescribing painkillers.

A spokeswoman for Pennsylvania Governor Tom Corbett told Medscape Medical News that the governor's administration was scrambling to investigate the "horrific" case. The head of the city health department said the agency needed "to do better."

Dr. Gosnell, 69, seemed to have followed the rules initially in his medical career, according to the grand jury report, but eventually became known on the East Coast as someone who would perform illegal, late-term abortions, which often resulted in viable fetuses being aborted alive. His patients, many of them poor and minorities, hailed from as far away as North Carolina. Unlike legitimate physicians who perform abortions, Dr. Gosnell ignored the 24-hour waiting period between an initial consultation and the procedure that is required by Pennsylvania law. His was a same-day business. The grand jury minced no words in characterizing him: "Butcher of Women."

Last week, Dr. Gosnell was charged with the murder of 7 newborn infants and a Bhutanese immigrant named Karnamaya Mongar, who died of a cardiac arrest in 2009 following a meperidine (Demerol) overdose dispensed by unlicensed, untrained, and unsupervised clinic employees. Other criminal charges include aborting fetuses past the state's legal limit of 24 weeks, violating the state's controlled substance law, abusing corpses, and corrupting the morals of a minor whom Dr. Gosnell hired at age 15 to work at his inner city clinic.

Dr. Gosnell, in jail without bail, was not available for comment. A spokeswoman for Philadelphia District Attorney Seth Williams said neither her office or the district court know of any attorney representing Dr. Gosnell, who has yet to enter a plea.

The grand jury also indicted 9 clinic employees with many of the same crimes, including murdering Mongar and infants aborted alive, and performing illegal abortions. These individuals included Dr. Gosnell's wife Pearl Gosnell and 2 medical school graduates who were posing as licensed physicians (one of them, Eileen O'Neill, had been licensed in Louisiana until 2000).

Clinic Went 16 Years Without State Inspection Despite Complaints

Much of the grand jury's reproof was reserved for the state Department of Health (DOH), which was responsible for overseeing abortion clinics. The DOH first approved Dr. Gosnell's clinic, grandly called the Women's Medical Society, to perform abortions in December 1979 after a site inspection.

The agency continued to certify the clinic as an abortion provider, although subsequent site inspections were sporadic through 1993. These visits unearthed violations such as the lack of a board-certified obstetrician/gynecologist on staff or listed as a consultant (Dr. Gosnell himself was not boarded in this specialty), that no licensed nurses were on hand to supervise the recovery of patients, and that pathology reports required for second-trimester abortions were missing.

Then, sometime after 1993, DOH went from "supposedly" inspecting abortion clinics on an annual basis to inspecting them only when the department received a complaint. DOH officials, according to the grand jury report, said that the administration of former governor Thomas Ridge, who took office in 1995, opposed routine inspections lest they uncover violations — specifically, those requiring emergency egress by wheelchair and stretcher — that would shut down the clinics and make abortion services less available to women.

However, the DOH failed to inspect the clinic — much less revoke its license — for the next 16 years, despite at least 2 complaints of patients suffering harm under Dr. Gosnell's care. In one case, a woman's uterus was perforated. In another, a pediatrician named Donald Schwarz, MD, MPH, who is now head of the Philadelphia health department, said that patients he referred to the clinic came back infected with venereal disease. There were other serious warnings, such as a report that Dr. Gosnell had aborted a 30-week-old fetus, the notification of Mongar's death in 2009, and inquiries from malpractice attorneys.

DOH inspectors finally returned to the clinic on the evening of February 18, 2010, when they accompanied Federal Bureau of Investigation and other law enforcement agents on the drug raid. What they saw — and smelled — was appalling.

"There was blood on the floor," the report stated. "A stench of urine filled the air. A flea-infested cat was wandering through the facility, and there was cat feces on the stairs. Semi-conscious women scheduled for abortions were moaning in the waiting room or the recovery room where they sat on dirty recliners covered with blood-stained blankets."

One federal agent likened the 2 surgical procedure rooms to a "bad gas station bathroom" on account of their filth and rusty, outdated equipment. Except for a blood pressure cuff in the recovery room, there was no working resuscitation — or even monitoring — equipment. In addition, narrow hallways did not allow patients to be evacuated on stretchers.

Then there were the remains of 45 fetuses, refrigerated or frozen in bags, milk jugs, and even cat food containers. A row of jars contained severed feet. Dr. Gosnell said he kept the feet for DNA evidence in the event of disputed paternity — a claim authorities considered preposterous.

Following the raid, DOH resumed regular inspections of abortion clinics in Pennsylvania. Nevertheless, the grand jury report quoted DOH lawyers as saying the state's abortion law gives the department little power over these facilities — a view the grand jury rejected.

State Medical Board Looked the Other Way, Grand Jury Says

The Pennsylvania State Board of Medicine acted quickly after the raid, suspending Dr. Gosnell's license. That board, part of the Pennsylvania Department of State, also came under heavy criticism from the grand jury for acting too late.

The Department of State literally licensed Gosnell's criminally dangerous behavior.

"The Department of State," said the grand jury report, "literally licensed Gosnell's criminally dangerous behavior."

As early as a decade ago, the state medical board received a complaint from a former clinic employee about dirty and unsterilized conditions, unlicensed workers, roaming cats, unsupervised sedation, underage abortion patients, and overprescribing of pain pills.

A state investigator looked into it. He interviewed Dr. Gosnell off-site, but never went inside the clinic, talked to employees, or examined records, according to the grand jury report. The complaint was dismissed as unconfirmed.

More "official neglect" ensued when the state medical board got wind of subsequent warning signs. In 2002, a malpractice insurer reported paying $400,000 to the family of a young woman who died of infection and sepsis after Dr. Gosnell had perforated her uterus and cervix during an abortion. The Pennsylvania Department of State chose not to take disciplinary action, with a medical board attorney stating "the risk was inherent with the procedure." At least 2 other reports of malpractice suits against Dr. Gosnell — said to be numerous — also were dismissed.

"Like their colleagues at [DOH]...Department of State officials were repeatedly confronted with evidence about Gosnell, and repeatedly chose to do nothing," the grand jury report stated.

What further galled the grand jury was that, according to its report, both the DOH and the Department of State evaded their duties by claiming each other had jurisdiction when confronted with the details of Dr. Gosnell's career. In addition, they did not ask each other for information on Dr. Gosnell in their files or volunteer to share it — actions that could have allowed authorities to connect the dots much earlier and shut down the clinic.

At the highest levels of Pennsylvania state government, the response to the grand jury report is one that reflects a change in political power and responsibility. Dr. Gosnell operated his abortion clinic under 5 different Pennsylvania governors. Last November, Tom Corbett was elected governor, inheriting the scandal from his predecessors. He was sworn into office the day before the grand jury report went public.

Medscape Medical News inquiries to the Pennsylvania DOH and Department of State were directed to Corbett spokesperson Janet Kelly. She told Medscape Medical News that the governor's office is fielding media calls because Corbett's nominees to head the Pennsylvania DOH and Department of State are just getting on the job, and the entire new administration is still unpacking its boxes. "Until we get organized, we're going to have [media requests] come through here," she said.

Governor Corbett, Kelly added, has called the grand jury report "horrific" and directed his nominees for secretaries of health and state to "review the grand jury report, see where the problems and loopholes are, and try to fix them." They are expected to report back to Corbett shortly, she said.

City Health Department Nurse Tried to Blow the Whistle

The grand jury's account of regulatory collapse also hit close to home in Philadelphia, where Dr. Gosnell practiced.

The city health department, for example, had dealings with his clinic. Dr. Gosnell participated in a children's vaccination program administered by the department, and thus was subject to inspection. He was repeatedly suspended for storing vaccines in filthy refrigerators at improper temperatures and failing to maintain vaccination logs.

A visit by registered nurse Lori Matijkiw from the city health department in 2008 was especially revelatory. In a memo to her superiors, Matijkiw described filth, the smell of urine, expired vaccines, missing vaccination records, and large plastic containers with blood-colored contents inside a freezer, its bottom covered with a red, frozen fluid.

The health department suspended Dr. Gosnell one more time from the vaccination program. A year later, Matijkiw visited the clinic again when Dr. Gosnell attempted to re-enroll in the vaccination program. She wrote another "scathing" report to her superiors, including evidence to suggest that Eileen O'Neill was practicing without a license and that abortions were being performed in Dr. Gosnell's absence.

The grand jury acknowledged that the city health department lacks the authority to regulate physicians or abortion clinics. It nevertheless faulted the agency — and Matijkiw's superiors in particular — for not reporting problems at the Women's Medical Society to authorities, such as the state medical board, that could take action against Dr. Gosnell.

Likewise, the environmental engineering section of the city health department received an anonymous complaint in 2003 that Dr. Gosnell stored aborted fetuses in paper bags inside a refrigerator. Yet there is no evidence that the department took any action against Dr. Gosnell "for his dangerous handling of medical waste, or for his failure to have an approved infectious waste plan," according to the grand jury report.

The report gave a mixed review to Philadelphia Health Commissioner Dr. Donald Schwarz, who has occupied that position since 2008. On one hand, it faulted him for seeming to absolve department personnel who ignored the threat posed by Dr. Gosnell's clinic and for offering feeble excuses on their behalf. On the other hand, it credited Dr. Schwarz with personally taking responsibility for the department's performance and acknowledging problems such as poor communication and a passive "it's-not-my-job" mind-set that dissuaded employees from reporting Dr. Gosnell to the state medical board and other authorities.

The grand jury also credited Dr. Schwarz with hand-delivering a complaint to the state DOH some 14 years about girls contracting venereal disease after undergoing abortions at Dr. Gosnell's clinic. Dr. Schwarz, then a practicing pediatrician, stopped referring patients to the clinic at that time, after he sent a social worker to pay a visit. The grand jury found no evidence that DOH responded to the complaint, much less filed it away. Dr. Schwarz said he never heard back from the state.

In an interview with Medscape Medical News, Dr. Schwarz said the grand jury report omitted an instance of the city health department reporting Dr. Gosnell to the state medical board in the late 1990s after a site visit uncovered unsanitary conditions. He said this departmental action came to light after the grand jury concluded its investigation. The department has no way of knowing, he added, what the state medical board did in response to the complaint.

The seeming lack of action on the part of the state, said Dr. Schwarz, helps explain, but not justify, why a senior department official did not file a complaint on Dr. Gosnell with the state medical board after the 2 site visits by Matijkiw in 2008 and 2009.

"He was preparing the report, but he never submitted it," said Dr. Schwarz. "He saw no urgency to it. In the past, he had gone to the state board, and nobody did anything."

We need to do better.

Dr. Schwarz said the city health department is assessing its role in the Gosnell case and taking a harder look at other Philadelphia physicians who perform abortions.

"We need to do better," he said.

Physicians Did Not File Required Complication Reports

Another group of witnesses to Dr. Gosnell's "careless and criminal practices" were physicians at the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center, who treated women with complications after abortions at Dr. Gosnell's clinic, according to the grand jury report.

Pennsylvania law requires any physician who treats abortion-related complications to file a report with the DOH. The grand jury report stated that at least 5 of Dr. Gosnell's patients — and probably many more — were treated at HUP and Penn Presbyterian for such complications, which included perforated organs and fetal remains left in the uterus. Yet the DOH turned over no such reports when the grand jury subpoenaed these documents. For its part, HUP produced a single complication report that it had filed with DOH in the death of one patient ("which raises the question why DOH did not turn over this report").

We are very troubled that almost all the doctors who treated these women routinely failed to report a fellow physician who was so obviously endangering his patients.

"We are very troubled that almost all the doctors who treated these women routinely failed to report a fellow physician who was so obviously endangering his patients," the grand jury stated.

Both HUP and Penn Presbyterian are both part of Penn Medicine, an academic medical center associated with the University of Pennsylvania School of Medicine.

Medscape Medical News asked Penn Medicine to comment on the accuracy of the grand jury report — in particular, the claim that its physicians failed to blow the whistle on Dr. Gosnell — and on whether Penn Medicine was assessing its role in the case. In response came an email from Susan Phillips, a senior vice president for public affairs at Penn Medicine: "Like everyone in the medical community, we are shocked at the additional revelations of the poor medical care provided to women in our community," Phillips writes. "Starting in 1999, Penn Medicine provided reports to the authorities regarding patients of Dr. Gosnell who sought additional care in our hospitals and we continue to monitor our reporting procedures. We have cooperated fully with the District Attorney's office during the investigation and hope that the courts will act in the best interests of patients."

"Infants Without Identities"

The grand jury issued stiff recommendations to "address systematic flaws" that allowed Dr. Gosnell to warehouse fetal remains and display their feet in jars for so many years.

"Anyone responsible for permitting Gosnell to operate as he did should face strong disciplinary action up to and including termination," the grand jury report stated.

Beyond that, the grand jury recommended the DOH should subject abortion clinics to the stricter licensing and oversight requirements — mandatory annual inspections, for example — that apply to ambulatory surgical facilities in Pennsylvania. The grand jury also said that the DOH should tighten up its regulation of abortion providers, such as requiring a boarded obstetrician/gynecologist to perform second-trimester abortion, as opposed to merely requiring that such a boarded physician be available for consultation.

The grand jury's prescription for public safety included a freer flow of information about cases such as Dr. Gosnell's between the DOH, the state medical board, the Philadelphia health department, and law enforcement agencies. In addition, the DOH and the state medical board should make it easier for individuals to file complaints about abortion providers, and they should follow up on them more rigorously, the report said.

The grand jury offered one reason for why Dr. Gosnell was able to operate his "baby charnel house" for so long that is less amenable to the corrective power of new laws, policies, and procedures: "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 subject of abortion."

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