Pennsylvania Govt. Did Not Inspect Gosnell Clinic for 17 Years

Witnesses in the Kermit Gosnell murder case allege that the women who died in his clinic were victims of negligence not only from the abortionist himself but from the Pennsylvania state government.

The Pennsylvania Department of Health stopped inspecting abortion clinics in 1993 except for complaints given directly to them. However, the grand jury in the Gosnell case found that the DOH did not inspect the Women’s Medical Society after they received many complaints.

22-year-old Semika Shaw died after she had an abortion in Gosnell’s clinic, and in January of 2002, her attorney demanded inspection reports from the DOH. Director of DOH’s Division of Home Health, Janice Staloski, who was one of the inspectors at Gosnell’s clinic in 1992, told the attorney there were none, because no complaints were received since 1993.

However, the DOH did receive several complaints of severe malpractice within that time frame. In 1996, an attorney for a different patient told Staloski’s predecessor, “his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell’s negligence.” The complaint was documented and given to the grand jury.

Another complaint, filed between 1996 and 1997, was not given to the grand jury. Dr. Donald Schwarz, now Philadelphia’s health commissioner, is a pediatrician and former head of adolescent services at Children’s Hospital of Philadelphia and directing physician of a private practice. He would refer patients to abortion providers, including Gosnell. But he and his partners noticed a lot of those females would return to them with trichomoniasis, a sexually transmitted parasite. 

Dr. Schwarz had a social worker talk to people at Gosnell’s clinic and, based on the visit, stopped sending his patients. He also hand-delivered a complaint letter to the office of the Pennsylvania Secretary of Health. He never heard back from the DOH and the department did not give a copy of the complaint to the grand jury.

Shaw’s family attorney was not the only lawyer to contact Staloski in 2002. Yet the official did not order an investigation into the clinic, even though situations were serious enough to have attorneys involved.

It continued to get worse, and the DOH still did not do anything. Dr. Frederick Hellman, the medical examiner for Delaware County, told the DOH about a 30-week-old stillborn baby girl. The medical examiner Irene LaFlore spoke to many at the DOH, including DOH Senior Counsel Kenneth Brody. A 14-year-old girl, while induced for an abortion by Gosnell, delivered the 30-week-old stillborn. It is illegal to abort a child after 24 weeks in utero. Brody correctly told Dr. Hellman to tell the district attorney, but the DOH still did not investigate the clinic.

In November 2009, a woman named Karnamaya Mongar died at Gosnell's clinic. Mongar was a 41-year-old woman who had recently left a resettlement camp in Nepal to live in America.

Gosnell told the DOH Mongar died at his clinic following an abortion. But the true account of her death, according to the grand jury report, was far more horrific:

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...

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.

Darlene Augustine received the fax from Gosnell with his version of events and told her boss Cynthia Boyne. Boyne became DOH’s Director of the Division of Home Health in 2007, when Staloski was promoted to head the Bureau of Community Licensure and Certification. Augustine told Boyne to investigate the clinic, even though she could order it herself.

Boyne instead went to Staloski, since she had previous experience. Staloski only wanted to charge Gosnell with failing to file the report in a timely and proper manner. The chief counsel for DOH, Christine Dutton, defended Staloski. She insisted the department was responsive and gave a chilly response when asked if the death of a woman after an abortion was suspicious or should be reported to law enforcement. “People die,” she said.

Even though all of these cases warranted an investigation into the clinic, the DOH never stepped in. Not until the February 2010 FBI raid which led to Gosnell's arrest did they finally take action. 


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