Summary of the grand jury report on Kermit Gosnell

The Grand Jury published their 280 page report in January 2011. They stated that, while some might see the issue and case through the lens of pro- and anti-abortion politics, it was in reality:

"not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants. We find common ground in exposing what happened here, and in recommending measures to prevent anything like this from ever happening again."[1]:1

Extreme unsanitary conditions, including STDs, septic (unsterile) conditions, blood and animal feces and urine and other noxious fluids and waste, and fetal remains stored in "jars, bags and jugs";[1]:1-2

Surgical malpractice including perforation of bodily organs and "on at least two occasions" death;[1]:1

Improper equipment and usage, including repeated reuse ("over and over") of disposable supplies, and "generally broken" life-saving and monitoring equipment (including blood pressure monitoring, oximeters, and defibrillators);;[1]:2

Lack of properly trained staff, staff misrepresented as being clinicians, and no qualified nurses.[1]:2 (Ex-employee Marcella Choung, who in 2001 and at interview in 2002 gave a detailed written complaint to the Pennsylvania Department of State, testified that her 'training' for anesthesia consisted of "a 15-minute description by Gosnell and reading a chart he had posted in a cabinet."[1]:52)

Operation of a "prescription treadmill" whereby blank signed prescriptions would be left for those seeking controlled medications, unsupervised and uncontrolled by a practitioner (which was the subject of a parallel and separate Federal investigation);[1]:2

Willful non-compliance with laws intended to safeguard vulnerable women, including non-compliance with requirements for mandatory counseling, consent (for minors), waiting periods (between visiting and surgery);[1]:3

Temporary employment of a nurse for 4 days during an NAF inspection, with the aim of deceiving the inspectors into believing that his practice staff included a licensed registered nurse (which it did not), over the few days of their on-site review - the nurse resigned upon realizing the fraud, which also involved Gosnell taking her paycheck back afterwards and paying her in cash instead;[1]:91-92

Fraudulent recording of gestational age and training of staff to manipulate ultrasound in a way that would match the stated number of weeks;[1]:3-4

Patients given labor and delivery inducing drugs during the day, then left waiting until late evening for Gosnell to attend or for surgery.[1]:4 Many gave birth during the day as a result, and employees testified "it was standard procedure for women to deliver fetuses – and viable babies – into toilets" while waiting for his arrival.[1]:4,64

Practice staff routinely delivered living babies in the third trimester, subsequently killing them (or ensuring their death).[1]:1 As part of this, fetuses and babies had their demise "ensured" post operatively by severing of the spinal cord with scissors, known by staff as "snipping". Most of these were deemed infeasible to prosecute because files and other evidence were not held, although the report stipulates they numbered in the "hundreds". Among the "few cases" where tangible evidence existed, the jury noted a boy aged 30 weeks at 6 pounds, a frozen body in a water container of "at least" 28 weeks, and testimony of a baby left "moving and breathing for at least 20 minutes" prior to "snipping". The jury suspected that the special Sunday sessions, at which only Gosnell and his wife were present, may have covered cases of even more age, or more disturbing;[1]:5-6

Where induced labor failed, Dr Gosnell would attempt to abort surgically, "often calamitous[ly]" for the woman involved. Example outcomes included:[1]:5-8, 66-69

Woman "left lying in place for hours after Gosnell tore her cervix and colon", relatives called police after entrance refused, remedial colon surgery required

Woman sent home with fetal remains unremoved, "serious infection" led to near death

Punctured uterus leading to shock from blood loss and hysterectomy, woman "held for hours" by the practice

Patient suffered "convulsions" and fell off the operating table sustaining a head injury, Gosnell "wouldn’t call an ambulance, and wouldn’t let the woman’s companion leave the building so that he could call an ambulance"

Sedation used to mute sounds of pain, Gosnell specified pre-set amounts of drugs for non-physician staff to use on patients, but without reference to individual needs, and without records or monitoring of condition. On numerous occasions the same patient was dosed multiple times in quick succession by different employees;[35]

Death of Karnamaya Mongar, who received "repeated unmonitored, unrecorded intravenous injections of Demerol" (meperidine hydrochloride, an opioid analgesic which the report describes practice staff using as a cheap but dangerous sedative), and ceased breathing. Staff were unable to revive her (emergency medications were not used and the defibrillator was not working), and paramedics were unable to revive her after gaining access, in part because they were deceived by staff as to what had happened and the drugs and dosages responsible

Gosnell was "caught by accident" after a raid for illegal prescribing revealed the conditions to officers involved;[1]:8

Pennsylvania Department of Health failed to regulate properly and failed to ensure that the issues noticed were addressed on the few occasions around 1990 that Gosnell was inspected, and ceased inspections "for political reasons" (to reduce a perceived deterrent) at the time Tom Ridge was appointed Governor of the State;[1]:8-9

Inspections were still to continue if complaints were received, yet repeated complaints did not trigger an investigation: the department's response came after media exposure;[1]:8-9

The Department of State's Board of Medicine, which licenses and oversees physicians, had "more damning information than anyone else" including a description of the practice by an ex-employee (Choung) a decade previously (2001 and again 2002), as well as knowledge of at least one of the serious incidents cited of surgical malpractice, but took verbal assurances from Gosnell and no other effective or substantial investigative action over these;[1]:10-11

Department of Public Health employees "regularly" visited the practice but had not adequately reported the issues present. One inspection confirmed "numerous violations of protocols for storage and disposal of infectious waste" but no follow-up occurred;[1]:11-12

A "health department representative" visiting for a vaccination program in 2009 "discovered that Gosnell was scamming the program" and "was able to file detailed reports identifying many of the most egregious elements of Gosnell’s practice." Her attempts to raise concerns were ignored - the Grand Jury report states "her reports went into a black hole";[1]:12

Other third parties had knowledge but took no visible action. These included the pediatrian and subsequent head of the city’s health department, Dr Schwartz, who around 1996-97 reported concerns about the practice to which no action was taken, and who did not himself act after being promoted, University of Pennsylvania hospital and Penn Presbyterian Medical Center who treated numerous surgical failures from Gosnell's practice including a "flagrantly illegal abortion" but only reported one of them, the National Abortion Federation whose evaluator around 2009 noted "records were not properly kept, that risks were not explained, that patients were not monitored, that equipment was not available, that anesthesia was misused" and concluded "[i]t was the worst abortion clinic she had ever inspected" but no report was made of this to any official body;[1]:12-13

The report divided offences by Goswell and other practice employees into three categories - "charges arising from the baby murders and illegal abortions; charges in connection with the death of Karnamaya Mongar; and charges stemming generally from the ongoing operation of a criminal enterprise". The charges recommended were:[1]:13-15

Gosnell, Williams, Moton, and Massof - charged with first degree murder for the post operative killings where evidence existed that the baby was born alive

Gosnell, Williams, Moton, Massof, and West - charged with conspiracy to commit murder in relation to "hundreds of unidentifiable instances" of post-operative killings ("called "snipping" by staff)

Gosnell and (as co-conspirators) Williams, West, and Gosnell's wife - charged with various violations of the Abortion Control Act, including infanticide and illegal late-term abortions

Gosnell, Williams, and West - charged with third-degree murder, drug delivery resulting in death, violations of the controlled substance[s] act and conspiracy in regard to the death of Karnamaya Mongar

Gosnell, West, and Hampton - charged with hindering apprehension, and lying to the police, medical practitioners, and the grand jury about the circumstances of Mongar's death (Hampton was also charged with perjury in the same matter)

The Grand Jury also concluded that "Illegality was so integral to the operation of the Women’s Medical Society that the business itself was a corrupt organization":

Gosnell, Williams, West, Moton, Joe, Baldwin, Gosnell's wife, Massof, and O’Neill - charged with running that organization or conspiring to do so

Massof and O’Neill - charged with theft by deception for pretending to be doctors, and billing for their services as if they were licensed physicians, and (with Gosnell) conspiracy to this effect

Gosnell - charged with obstruction and tampering for altering his patient files to hide illegality, and for destroying or removing other files entirely

Gosnell and Baldwin - charged with corrupting the morals of a minor, by hiring her 15-year-old daughter as a staff member, who was "required to work 50-hour weeks, starting after school until past midnight, during which she was exposed to the full horrors of Gosnell’s practice".

"We believe, given the manner in which Gosnell operated, that he killed the vast majority of babies that he aborted after 24 weeks. We cannot, however, recommend murder charges for all of these cases. In order to constitute murder, the act must involve a baby who was born alive. Because files were falsified or removed from the facility and possibly destroyed, we cannot substantiate all of the individual cases in which charges might otherwise have resulted."[1]:115

The report also examined the failings of official parties, and the key findings, analyzed in two categories:[1]:15-16

"Janice Staloski of the Pennsylvania Department of Health, who personally participated in the 1992 site visit, but decided to let Gosnell slide on the violations that were already evident then. She eventually rose to become director of the division that was supposed to regulate abortion providers, but never looked at Gosnell despite specific complaints from lawyers, a doctor, and a medical examiner. After she was nonetheless promoted, her successor as division director, Cynthia Boyne, failed to order an investigation of the clinic even when Karnamaya Mongar died there. Senior legal counsel Kenneth Brody insisted that the department had no legal obligation to monitor abortion clinics, even though it exercised such a duty until the Ridge administration, and exercised it again as soon as Gosnell became big news. The agency’s head lawyer, chief counsel Christine Dutton, defended the department’s indifference: 'People die,' she said."

"Lawyers at the Pennsylvania Department of State behaved in the same fashion. Attorneys Mark Greenwald, Charles Hartwell, David Grubb, Andrew Kramer, William Newport, Juan Ruiz, and Kerry Maloney were confronted with a growing pile of disquieting facts about Gosnell, including a detailed, inside account from a former employee (Marcella Choung, 2001[1]:176-180), and a 22-year-old dead woman. Every time, though, they managed to dismiss the evidence as immaterial ... until the facts hit the fan."

Department of Health should explicitly regulate and annually inspect abortion practices, and examine patient files, licenses, and equipment on-site;

Second-trimester abortions should be performed or supervised by doctors who are board-certified obstetrics and gynecology;

Department of State "must repair its review process", including easier reporting, confidentiality, post-investigation response, with cases automatically checked against past records, malpractice databases, and full past history;

Reports about individual doctors checked against reports of medical offices where they worked, and vice versa;

Department of Public Health "should do at least as much to control infectious medical waste as it does to inspect swimming pools";

The conclusions finished by examining the extent to which legislation had been inadequate, and the scope for legislative change, concluding that:[1]:17

"Statutory changes are necessary as well. Infanticide and third-trimester abortion are serious crimes. The two-year statute of limitations currently applicable for these offenses is inadequate to their severity. The limitations period for late abortion should be extended to five years; infanticide, like homicide, should have none. Impersonating a physician is also a serious, and potentially very dangerous, act. Yet under current law it is not a crime at all. An appropriate criminal provision should be enacted. There may also be other statutory and regulatory revisions that we, as lay people, have not thought to consider. Legislative hearings may be appropriate to further examine these issues."

“They stated that, while some might see the issue and case through the lens of pro- and anti-abortion politics, it was in reality:
‘not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants...’”

It is a very small step to go from a pro-abortion position to disdain for the lives of infants. For example, those at DU hold Gosnell up as a hero.

He is either a butcher or a hero, depending on where you draw your line in the sand for the respect for life. There is no gray-area with Gosnell. For the pro-abortion crowd, that line in the sand has always been wide and fuzzy over the entire spectrum of abortions...and it makes them deeply uncomfortable to have to narrow the focus of that line. I suspect that this is why MSM coverage of this trial has been so sparse...they know their pro-abort readers/viewers prefer to avoid defining their morals to any set standard.

The court may choose to avoid the abortion controversy, but it is impossible for someone who is pro-abortion to know about this case and not apply moral absolutes to their life of relative morality.

What is so ironic is that the pro abortion people pushed legalized abortion as a way to eliminate back alley abortion clinics, which were horrible and unsafe. Now we have Kermit Gosnells practicing all over the country. He was caught “by accident”?? This is breathtaking.

Reading about Gosnell's house of horrors, I'm reminded of The Devil in the White City. If you haven't read it, it's the true story of a "doctor" who built a hotel opposite the Chicago World's Fair grounds for the expressed purpose of killing fair-goers and disposing of their bodies.

How is Gosnell any different?

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