Kermit Gosnell's Last Abortion

Gosnell: The Untold Story of America's Most Prolific Serial Killer, by Ann McElhinney and Philem McAleer, is eye-opening even for folks like me who followed the Gosnell story closely and delved deeply. Nobody has delved more deeply than Ann and Philem. I'm grateful to them.

It's a best-seller on Amazon, and for good reason. There's so much meat here, it's hard to know where to start, so I'll just start with Kermit Gosnell's last hurrah.

Darlene Augustine.and Elinor Barsony, two Department of Health nurses, accompanied the initial raid on Women's Medical Society.

Darlene Augustine had worked at the Department of Health since 1989, supervising inspectors who responded to complaints about health care facilities. She had gotten a fax from Kermit Gosnell on November 24, 2009 notifying the Department of Health about the death of Karnamaya Mongar after her abortion at his Women's Medical Society.

According to the Grand Jury Report, Ms. Augustine had the authority to send someone out to investigate. She often sent someone out within an hour of receiving a report of a serious incident. But since this serious incident involved abortion, she decided that she should run it up the chain of command. She presented the fax to her boss, Cynthia Boyne, to get permission to launch an immediate investigation.

Ms. Boyne supervised the Division of Home Health.  (For some reason only bureaucrats can fathom, the Division of Home Health was in charge of overseeing abortion facilities.) Rather than give the go-ahead, Ms. Boyne discussed the matter with her boss, Janice Staloski, who oversaw the entire Bureau of Community Licensure and Certification.

Boyne and Staloski told Ms. Augustine no. She was not allowed to start an investigation into the death of Karnamaya Mongar.

According to the Grand Jury Report, Ms. Augustine got instructions by senior Department of Health Attorneys Kenneth Brody and James Steele that when she accompanied law enforcement on the raid, she was to to reveal anything about Karnamaya's death. If she were asked about it, she was to refer the questions to the Department's attorneys.

She decided to go even farther. She told the other Department of Health nurse in the group, Elinor Barsony, not to even admit that they knew about Karnamaya's death.

In they went. Ann and Philem note:

Everything was covered in cat hair -- the chairs, blankets, and all the surfaces. The clinic's two surgical procedure rooms were filthy and unsanitary. .... Instruments were not sterile. Equipment was outdated and rusty. Women recovering from their abortions sat on dirty recliners covered with bloodstained blankets that the employees said they 'tried' to clean weekly. Unlicensed employees had sedated all of the women, long before Gosnell arrived. Staff members couldn't say for certain which medications they had administered. Many of the medications that the agents and the detectives found in inventory were well past their expiration dates.

Detective James Wood expressed his shock and disgust to Ms. Augustine, who stunned him by replying, "Well, you're just saying that because you're a cop."

Blood-encrusted and torn procedure room table

As she later testified in Gosnell's trial, Ms. Barsony noticed that the women in recovery weren't hooked up to any of the standard post-surgery monitors for things like blood pressure, pulse, and oxygen saturation. There was only one blood-pressure monitoring cuff on the premises, and it was dusty and dirty and obviously disused. As for the procedure rooms, "They had the trays for the procedure already opened, so they were sitting there exposed ... and they're supposed to be covered." The fact that they were sitting out open, and not being kept sterile prior to starting the abortion, meant that they were unsafe for use. The suction machine was in disrepair and could not allow an accurate measure of how much suction was being applied.

Two of the patients were in such bad shape medically that they needed to be hospitalized. Because the emergency exit was still padlocked and blocked with junk furniture and equipment and the hallways were so narrow and crooked, the paramedics couldn't get stretchers to the patients and had to walk them to the waiting ambulances.

Even after witnessing all of the filth and chaos, nurse Barsony decided to pass one patient's request along to her supervisors. Barsony called Cythia Boyne, who called Janice Staloski, with a question: Should Gosnell be allowed to use his unsterile instruments, expired medications, and dysfunctional suction machine to do one last abortion in his feces-encrusted, urine-spattered, flea-infested clinic?

Boyne and Staloski, the two health officials who had refused to green-light an investigation into a death at Gosnell's filthy facility, were willing to green-light an abortion there.

The Kermit Gosnell Debacle: January, 2002

Why you can't believe state officials if they say there's no problems at an abortion clinic, from the Grand Jury Report on Kermit Gosnell:

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.

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? Of these possible explanations, we are not sure which is the most troubling.