Philadelphia Weekly

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The case of Dr. Kermit Gosnell, the Philadelphia physician charged with murdering babies for decades uninterrupted in a wide-open darkness of institutional failure, offers many lessons and no simple solutions. A year-long investigation that included interviewing 58 witnesses culminated in a 281-page grand jury report published Jan. 19. The report relentlessly documents not only Gosnell’s crimes, but how he got away with it for so long. Here is a timeline of events, including inspections and complaints that led to nowhere, leading up to Dr. Kermit Gosnell's arrest:

Dec. 20, 1979: Pennsylvania Department of Health (DoH) grants first approval for the Women’s Medical Society to provide abortions.

Dec. 20, 1980: Approval expires.

August 1989: Next documented site review. Site reviewers recommend approval despite shoddy record-keeping and lack of nursing staff, among other violations.

March 1992: Next inspection. “There is nothing to suggest that these evaluators reviewed any patient files.” Nevertheless, evaluators Janice Staloski and Sara Telencio “inexplicably concluded that there were no deficiencies,” and DoH approved Gosnell’s clinic to continue to perform abortions.

April 8, 1993: Gosnell’s clinic inspected by DoH evaluators Susan Mitchell and Georgette Freed-Wolf. “Instead of making their own inspection, the evaluators appeared to have relied on representations by staff about procedures for cleaning and checking equipment.” It is the last inspection of Gosnell’s clinic—or any clinic in the state of Pennsylvania—conducted by DoH until after the raid.

July 23, 1993: Susan Mitchell recorded that the deficiencies had been corrected despite no follow-up.

1996: An attorney informs state Home Health Division that “his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell’s negligence.”

1996–1997: Dr. Don Schwarz, then a private practice physician (and Philadelphia’s current health commissioner), hand delivers a complaint to the DoH after noticing his patients contracting a sexually transmitted parasite after referring them to Gosnell’s practice.

March 2000: 22-year-old Semika Shaw dies at University of Pennsylvania after being treated by Gosnell. It is the only instance where the hospital filed reports of abortion complications and maternal deaths, as required by law. They did not report halting an abortion of a 29-week pregnancy, a woman arriving unconscious with fetal remains inside her, or the death of Mongar.

December 2001: Former Gosnell employee Marcella Stanley Choung filed a complaint with the Department of State outlining his entire operation, including the pill mill. Despite a follow-up interview March 4, 2002, that included Choung’s testimony that Gosnell performed abortions on “underage children” against their will and that unlicensed employees were administering anesthesia, “No one asked to see the facility or the files.”

2003: Philadelphia Health Department’s Environmental Engineering Section failed to follow through on complaint about aborted fetuses stored in the employee refrigerator.

April 29, 2004: A State Board of Medicine attorney recommends closing the case on Choung’s allegations.

May 7, 2004: City health department inspector checks clinic based on awareness that Gosnell has no medical waste plan for biohazard disposal as required by the city.

2004–2005: The department stopped trying to enforce the regulation against those who had not complied.

Aug. 2, 2005: Attorney William Newport of Bureau of Professional and Occupational Affairs is notified that Gosnell is not carrying liability insurance. He was not insured at all between July 15, 2004, and April 18, 2005.

September 2005: An attorney for a victim called “Alice” sent a copy of malpractice suit to the DoS that alleged that during a procedure, she convulsed, fell off the table and struck her head. Gosnell was not insured at the time of procedure.

March 4, 2006: Board of Medicine attorney David Grubb recommends closing the “Alice” case without investigation or prosecution. His supervisor agrees.

Nov. 11, 2006: Victim Dana Hayes alleges that Gosnell botched an abortion and recklessly tore her cervix, uterus and bowel. He locked her family members out for four hours and refused to call an ambulance as she bled out. She filed a civil malpractice suit. “No one [at DoS] thought Ms. Hayes’ complaint was worth investigating.”