Editor’s note. Abortionist Kermit Gosnell was arraigned last week and is charged with eight counts of murder. “How Did This Go On So Long?” is one of the key sections in the Grand Jury’s 261-page report. Today’s except is an explanation and enumeration of the many, many serious infractions the Department of Health found when it FINALLY investigated Gosnell’s Women’s Medical Society abortion clinic. We begin with the first paragraph of Section VI, which places the question in context.
The callous killing of babies outside the womb, the routinely performed third trimester abortions, the deaths of at least two patients, and the grievous health risks inflicted on countless other women by Gosnell and his unlicensed staff are not the only shocking things that this Grand Jury investigation uncovered. What surprised the jurors even more is the official neglect that allowed these crimes and conditions to persist for years in a Philadelphia medical facility. …
Department of Health evaluators found multiple grounds to shut down the Women’s Medical Society once they finally entered the facility.
It was not until February 18, 2010, when DOH representatives were escorted in by law enforcement agents, that they finally inspected the clinic that they had not bothered to visit in 13 years. This time, neglecting the horrors at 3801 Lancaster Avenue was no longer an option. Over the next few days, the DOH evaluators identified a multitude of violations of the Abortion Control Act and abortion regulations, many of which were apparent with even a cursory glance around the facility.
The abortion regulations promulgated by DOH (28 Pa. Code §29.33(1)) require that abortion providers have the following ready for use to resuscitate patients whenever anesthesia is used:
(i) Suction source.
(ii) Oxygen source.
(iii) Assorted size oral airways and endotracheal tubes.
(v) Bag and mask and bag and endotracheal tube attachments for assisted ventilation.
(vi) Intravenous fluids including blood volume expanders.
(vii) Intravenous catheters and cut-down instrument tray.
(viii) Emergency drugs for shock and metabolic imbalance.
(ix) An individual to monitor respiratory rate, blood pressure, and heart rate.
When patients are sedated to the point of being deeply asleep, as they were when Gosnell performed second-trimester abortions, additional equipment is required. Even when the sedation is less deep – a level referred to as conscious sedation, in which the patient can still respond to verbal instructions – Pennsylvania regulations require that additional equipment be readily available, including a “monitor defibrillator with electrocardiogram visual display of heart rate and rhythm” (ECG) and a pulse oximeter.
Women’s Medical Society effectively had none of this. A document filed by DOH on March 12, 2010, referred to as an “Order to Show Cause,” laid out several grounds for shutting the clinic. It stated that the only items on the list that were in the facility in any form were suction and oxygen sources and an unusable monitor defibrillator and ECG. Yet there was only one suction source for each procedure room, meaning that the same suction source used to perform the abortion would have to be used to resuscitate patients. The DOH document noted, moreover, that neither suction machine had an inspection sticker to indicate that it was functioning properly. The suction tubing on both machines was corroded, according to the report.
As for the supposed oxygen sources, DOH noted:
One oxygen source was an E cylinder oxygen tank that lacked a label to indicate whether the tank was full or empty. The oxygen mask and tubing hanging from the tank were covered in a thick gray layer of a substance that appeared to be dust. … The other oxygen source at the … facility was an oxygen concentrator covered with a thin layer of dust. The oxygen concentrator bore no inspection sticker and no evidence of inspection to assure proper functioning. There was no oxygen mask or tubing with theoxygen concentrator.
The DOH document stated that the monitor defibrillator and ECG not only had no inspection sticker, but was unusable because there were no electrodes to attach to the machine. Latosha Lewis testified that the machine had been broken for at least six years.
As the DOH Order to Show Cause noted in “Count I,” each time Gosnell performed a procedure without the required equipment and drugs for resuscitation, he violated the abortion regulations §29.33(1). He also violated §29.33(4) by failing to have a doctor certified by the American Board (or Osteopathic Board) of Obstetrics and Gynecology either on staff or available as a consultant. (Count II.) The Department of Health also cited the clinic for failing to conduct or to record required lab tests in violation of §29.33(6). (Counts III and IV.)
After entering Gosnell’s facility with law enforcement agents, DOH representatives reviewed the files of some of its patients (some of whom were present and had procedures on February 18, 2010, when the search was conducted; and some of whom had had procedures in the previous few months). Nine of the patients had had second-trimester abortions. Under Pennsylvania’s abortion regulations, abortion providers are required to send any tissue from second-trimester procedures to a pathologist to determine whether there is evidence of viability. Gosnell had failed to do this for any of the nine patients, thus violating §29.33(8) nine times. (Count V.)
The Department of Health also charged Gosnell’s clinic with failing to have written procedures and policies for the administration of anesthesia and for failing to maintain a list of employees permitted to administer it. These failures constituted violations of §29.33(12). (Count VI.) Other violations detailed by DOH in March 2010 were the failure to have patients in recovery monitored by a registered nurse or a licensed practical nurse, or to have such nurses enter the doctor’s orders in the patients’ medical records as required by §29.33(13). (Counts VII and VIII.)
The DOH document stated (in Count IX) that the clinic violated §29.33(14) of the abortion regulations by failing to have corridor doors and passages adequate in size and arrangement to allow a stretcher-borne patient to be moved from each procedure room and recovery room to a street-level exit. DOH noted that ambulance crews on February 18, 2010, had wanted to evacuate two patients from Gosnell’s clinic on stretchers, but instead had to help them walk through the corridors. The situation was made even worse because the closest exit door to the street was padlocked shut, and the staff could not find the key.
Count X alleged that Gosnell failed to ensure that one of the patients having an abortion on February 18, 2010, had a private consultation regarding the necessity of her abortion, as required by §29.32. Count XI stated that the clinic failed to report the death of Karnamaya Mongar within 24 hours as required under 40 Pa.C.S. §1303.313(a) (the Medical Care Availability and Reduction of Error, or MCARE, Act).
Count XII spelled out a violation of §29.38(a)(5) of the abortion regulations, which requires doctors to file a “Report of Complication” with DOH any time they treat a patient as a result of a complication from an abortion. The complication that Gosnell treated, but allegedly did not report, was the cardiac arrest suffered by Karnamaya Mongar.
Count XIII accused the clinic of violating §29.38(5), which requires abortion providers to file quarterly reports with DOH, stating the number of abortions performed by the facility in each trimester of pregnancy. The most recent report filed by Gosnell’s clinic stated that it had performed 118 first-trimester and 2 second-trimester abortions in the fourth quarter of 2009. But even in the few files that DOH evaluators reviewed in February 2010, there were six second-trimester procedures performed in the last two months of 2009.
The last count in the DOH document – Count XIV – cited the failure to file reports on every abortion performed, as required by §29.38(3). Specifically, DOH stated that Gosnell did not file reports on six of the women whose files DOH reviewed in February 2010. This failure violated the abortion regulations and constituted grounds for revoking DOH approval to perform abortions.
Indeed, each of the violations enumerated by the DOH Order to Show Cause constitutes grounds for revoking the clinic’s approval to perform abortions under §29.43(d) – many times over, in fact. Once the DOH inspectors entered the facility in February 2010, they did a thorough job of inspecting Gosnell’s clinic and moved quickly to revoke its “approval,” based on the clinic’s many flagrant violations of law.
The travesty, from this Grand Jury’s perspective, is that DOH could and should have closed down Gosnell’s clinic years before. Many, if not all, of the violations cited in the March 12, 2010, document had been present for nearly two decades. The violations had been apparent when DOH site-reviewers, including Susan Mitchell and Janice Staloski, inspected the facility in 1989, 1992, and 1993. Yet it was not until law enforcement discovered the horrendous conditions inside 3801 Lancaster Avenue that DOH took action to close the clinic.
The state Department of Health monitors other comparable health care facilities to assure quality care.
The Department of Health’s decades-long neglect of its duty to ensure the health and safety of women undergoing medical procedures in abortion clinics is in stark contrast to its policies and practices with respect to procedures performed in other types of health care facilities. …