Inside the freezer, investigators found the fully intact 19-week fetus “delivered” by Mongar the night of her death three months earlier.
Many people had gotten a glimpse into Gosnell’s grisly operation. But multi-level, panoramic, institutional negligence, a culture of passing the buck and flagrant disregard for patient’s welfare prevented any meaningful investigation.
“Most appalling of all,” states the grand jury report, “the Department of Health’s neglect of abortion patients’ safety and of Pennsylvania laws is clearly not inadvertent: It is by design.”
After 1993, “the Pennsylvania Department of Health abruptly decided, for political reasons, to stop inspecting abortion clinics at all … With the change of administration from Governor [Bob] Casey to Governor Ridge, officials concluded that inspections would be ‘putting a barrier up to women’ seeking abortions,” the report says.
That fatal decision was enacted by Gov. Tom Ridge, a pro-choice Republican, in response to the legacy inherited by Gov. Casey, a pro-life Democrat who passed landmark legislation in Pennsylvania that enabled states to restrict women’s access to abortion.
Not only did inspections systematically stop in 1993, red flags were ignored. They include a former employee’s complaint that “laid out the whole scope of [Gosnell’s] operation,” and a malpractice lawsuit over the death of 22-year-old Semika Shaw, a mother of two children who died of sepsis at University of Pennsylvania hospital after Gosnell punctured her uterus.
The lawsuit was settled for almost a million dollars.
Local negligence added additional layers to the complex matrix of oversight failure. For example, “Penn could not find a single case in which it complied with its legal duty to alert authorities” in cases where emergency room physicians had to treat ramifications of Gosnell’s botched procedures, as required under the Abortion Control Act.
As a private physician treating teenage girls in West Philadelphia, Dr. Donald Schwarz—currently Philadelphia’s health commissioner—noticed a pattern of his patients becoming infected with Trichomoniasis, a sexually transmitted parasite, after appointments at Gosnell’s clinic. Schwarz testified to the grand jury that about six years ago, he “hand-delivered” a complaint about Gosnell’s clinic to the Pennsylvania Department of Health.
Yet in his two years as the city’s health commissioner, he did not check into Gosnell’s practice. In addition to his personal knowledge of problems, the Philadelphia Department of Health was aware that Gosnell never submitted a infectious medical waste removal plan—the reason fetuses and body parts littered on the premises.
Schwarz testified that medical waste regulations were established with the sole goal of making money for the city. “The department was told, apparently, to collect the money, make sure the plan came in, get the fee, and not enforce, that is don’t take action against people … This is a revenue-generating activity.”
The hand-delivered complaint did not exist among the records subpoenaed by the grand jury.
Though the report documents up-the-chain failures, the aerial-view conclusion regarding oversight is that even if all the proper protocols were followed and complaints filed, the state Department of Health would have continued ignoring warning signs, no matter what.
“If Dr. Schwarz’s complaint did not trigger an inspection, we are convinced that none would,” the jury stated.
“Pennsylvania is not a third-world country,” asserts the report. “There were several oversight agencies that … should have shut down Kermit Gosnell long ago. But none of them did.”
And so, with the eyes of the state averted, Gosnell and his staff—the clinic was run by a tight-knit group of relatives and friends—were able to get away with regularly scheduled murders.
A Typical Day at the Office
Amidst the filth and chaos, the clinic ran a predictable program: Every Monday, Tuesday, Thursday and Saturday morning around 10 a.m., a motley, cult-like group of unqualified employees—including Gosnell’s 49-year-old wife, Pearl, failed wannabe doctors and a high school student—opened up shop. Gosnell spent his days swimming, jogging or relaxing at home and only came to work at night and Sunday afternoons.
During the week, according to the grand jury, “Gosnell routinely aborted and killed babies in the sixth and seventh month of pregnancy.” On Sundays, Gosnell and his wife (charged with performing illegal abortions and conspiracy, among other crimes) performed the most blatantly illegal third-trimester abortions. “The Sunday babies must have been bigger still,” the report says. “We may never know the details of these cases.”
Journalist Steve Lopez once wrote that Philadelphia is a city without pretense in a state without shame—and that was long before Harrisburg legislators stooped low enough to exploit murdered babies to push a bill into law that would result in what critics call a “back-door ban” on abortion in Pennsylvania.
Nine months after a grand jury concluded that the number of babies and women who died in Kermit Gosnell's women's health services clinic is “literally incalculable,” a pair of guerilla artists sent out invitations to a renegade art installation titled Regard, to be showcased by lights tonight at the former site.
Under the leadership of 44-year-old Troy Newman, Operation Rescue has become known for zeroing in on defined areas and then pressuring individual clinics and practitioners until operating becomes unreasonable or impossible.
A timeline of events in the case against Dr. Kermit Gosnell.
Last year, in the wake of the arrest of Kermit Gosnell, Operation Rescue came to town. They met in the basement of St. Agnes Church in West Chester. As PW reported in March, the militant anti-abortion organization was there recruiting volunteers to gather doctors’ names and schedules by pretending to be mothers of daughters who were seeking abortions.
PW's 2015 Philly Spring Guide