The Department of Health's Complicity in Gosnell's House of Horrors

What the Grand Jury learned about the Pennsylvania Department of Health boggles the mind. Frankly, I think some of those people should be up on charges. They belong in jail with Gosnell and his seedy staff.

I'd appreciate any of my trusted readers who are willing and able to help with this daunting task of wikifying the Grand Jury Report.

I'll just share a few snippets:

We discovered that Pennsylvania’s Department of Health has deliberately chosen not to enforce laws that should afford patients 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.

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Indeed, the department has shown an utter disregard both for the safety of women who seek treatment at abortion clinics and for the health of fetuses after they have become viable. State health officials have also shown a disregard for the laws the department is supposed to enforce. Most appalling of all, the Department of Health’s neglect of abortion patients’ safety and of Pennsylvania laws is clearly not inadvertent: It is by design.

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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. (There is a notation on the 1989 report that a review was conducted in February 1986, but DOH could not provide any documentation of it in response to the Grand Jury’s subpoena.)....

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.... 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.

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There is nothing to suggest that these evaluators reviewed any patient files. Gosnell reported performing 62 second-trimester abortions in the previous year, yet the DOH inspectors left blank the section in their report on anesthesia, including who is permitted to give it, what their qualifications are, and the type of anesthesia they are permitted to administer. Also left blank was a section titled “Post-Operative Care,” which addresses the legal requirement that the recovery room be monitored at all times by a registered nurse or a licensed practical nurse under the supervision of a physician – the same regulation that the clinic was cited for violating three years earlier. Nevertheless, the evaluators inexplicably concluded on March 12, 1992, that there were “no deficiencies,” and DOH approved Gosnell’s clinic to continue to perform abortions.

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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. ....

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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 anesthesia 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.

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.

Janice Staloski, one of the evaluators of Gosnell’s clinic in 1992, 10 years later was the Director of DOH’s Division of Home Health – the unit that is inexplicably responsible for overseeing the quality of care in abortion clinics. In January 2002, an attorney representing Semika Shaw, a 22-year-old woman who had died following an abortion at Gosnell’s clinic, wrote to Staloski requesting copies of inspection reports for any on-site inspections of the clinic conducted by DOH. Staloski wrote to the attorney that no inspections had been conducted since 1993 because DOH had received no complaints about the clinic in that time.


Except that it had. In 1996, another attorney, representing a different patient of Gosnell’s, informed Staloski’s predecessor as director of the Home Health Division that his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell’s negligence. The Home Health director discussed this patient with DOH Senior Counsel Kenneth Brody, and the complaint report was documented in records turned over to the Grand Jury. It was surely available to Staloski when she inaccurately told the attorney in January 2002 that DOH had received no complaints regarding Gosnell’s clinic.

Not documented in the records turned over to the Grand Jury was a second complaint registered between 1996 and 1997. This one was hand-delivered to the secretary of health’s administrative assistant by Dr. Donald Schwarz, now Philadelphia’s health commissioner. Dr. Schwarz, a pediatrician, is the former head of adolescent

services at Children’s Hospital of Philadelphia and was the directing physician of a private practice in West Philadelphia. For 17 years, he treated teenage girls from the West Philadelphia community. Occasionally, he referred patients who wanted to terminate their pregnancies to abortion providers. Gosnell’s clinic was originally included as a provider in the referral information that Dr. Schwarz gave to his patients. He and his physician partners noticed, however, that patients who had abortions at Woman’s Medical Society were returning to their

private practice, soon after, infected with trichomoniasis, a sexually transmitted parasite, that they did not have before the abortions.


When this happened repeatedly, Dr. Schwarz sent a social worker to talk to people at Gosnell’s facility. Based on the social worker’s visit to Women’s Medical Society, Dr. Schwarz stopped referring patients to the clinic. He also hand-delivered a formal letter of complaint to the office of the Pennsylvania Secretary of Health. Dr. Schwarz told the Grand Jury that he does not know what happened to his complaint. He never heard back from DOH. And the department did not include it in response to the Grand Jury’s subpoena requesting all complaints relating to Gosnell's’ clinic. We know that no inspection resulted.


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. 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 suggests to us that there may have been many more complaints that were never turned over to the Grand Jury.

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In 2007, Dr. Frederick Hellman, the Medical Examiner for Delaware County, reported to DOH the stillbirth of a 30-week-old baby girl. A medical examiner investigator, Irene LaFlore, made the phone calls. She spoke to several DOH employees, including Brody, the senior counsel. The investigator reported to the DOH officials that the medical examiner had conducted an autopsy on the stillborn baby delivered by a 14-year-old girl at Crozier-Chester Medical Center. She explained that the baby’s delivery had been induced in the course of an abortion performed by Gosnell, and that the medical examiner was concerned because performing an abortion at 30 weeks was a clear

violation of the Abortion Control Act.


According to the investigator’s notes, Brody suggested that the medical examiner inform the District Attorney’s Office in Delaware County – for possible referral to Philadelphia, where the procedure occurred – because it was a crime to perform an abortion beyond 24 weeks. Brody said that neither DOH nor the state medical board had any authority over the matter. The senior counsel did ask the investigator to keep him informed. The investigator’s notes suggest Brody told her that, once the district attorney acted, then the medical board could get involved.

Brody was correct to refer Dr. Hellman to the district attorney to prosecute the abortion of the 30-week pregnancy as a crime. That, however, did not absolve DOH of its responsibility. The information provided by Dr. Hellman’s investigator should have been received as a complaint to DOH. The department should have initiated an investigation. DOH could have revoked the clinic’s license without waiting for a criminal prosecution that might never (and did not) happen. Yet no one from the department went to investigate Gosnell’s clinic.

Since February 2010, Department of Health officials have reinstituted regular inspections of abortion clinics – finding authority in the same statute they used earlier to justify not inspecting. Staloski blamed the decision to abandon supposedly annual inspections of abortion clinics on DOH lawyers, who, she said, changed their legal opinions and advice to suit the policy preferences of different governors. Under Governor Robert Casey, she said, the department inspected abortion facilities annually. Yet, when Governor Tom Ridge came in, the attorneys interpreted the same regulations that had permitted annual inspections for years to no longer authorize those inspections. Then, only complaint-driven inspections supposedly were authorized. Staloski said that DOH’s policy during Governor Ridge’s administration was motivated by a desire not to be “putting a barrier up to women” seeking abortions.

It goes on from there, and only gets worse. I'll be working on getting the Grand Jury's report up, in text, searchable, and cross-linked, as quickly as I can.