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.