Editor’s note.  Abortionist Kermit Gosnell stands charged of eight counts of murder. In this section–“How Did This Go On So Long?”– of its 261-page report, the Grand Jury notes that “The attorney representing the Hospital of the University of Pennsylvania doctors before the Grand Jury was able to produce only one confirmed report ever made (which raises the question why DOH did not turn over this report). That one report was for Semika Shaw, who died at the hospital.”


Pennsylvania’s Abortion Control Act requires any doctor who treats a woman because of a complication arising from an abortion to make a report to DOH [Department of Health]. Willful failure to do so constitutes “unprofessional conduct” and subjects the treating doctor to sanctions by the Board of Medicine. Clearly, this law is being violated, if not willfully, at least consistently. We learned of at least five of Gosnell’s patients who were treated for serious complications at the Hospital of the University of Pennsylvania (HUP) or Presbyterian Hospital, the two closest emergency rooms to the Women’s Medical Society clinic. We heard evidence of many more women, whose names we did not learn, who also had to seek emergency care after undergoing abortions at Gosnell’s facility. Yet we received no complication reports when we subpoenaed documents from DOH.

The attorney representing HUP doctors before the Grand Jury was able to produce only one confirmed report ever made (which raises the question why DOH did not turn over this report). That one report was for Semika Shaw, who died at the hospital in March 2000. Documents turned over to the Grand Jury show that, following Shaw’s death, another hospital attorney, Mary Ellen Nepps, distributed a memo to doctors at HUP and Pennsylvania Hospital. The memo reminded the physicians, “in light of some recent reports of abortion complications and maternal deaths,” that they were responsible for filing reports with DOH in such cases.

Yet, when Karnamaya Mongar died at HUP nine years later, no report was made. Nor did the Grand Jury receive evidence of reports made, other than in Shaw’s case, for any of the serious complications that other patients of Gosnell suffered. Dana Haynes went straight to the HUP emergency room from Gosnell’s clinic with a perforated cervix and bowel and most of a fetus still in her uterus. She required surgery and was hospitalized for five days. Another 19-year-old patient of Gosnell’s had a hysterectomy performed at HUP after Gosnell perforated her uterus. And Marie Smith arrived at Presbyterian Hospital, unconscious, with fetal remains still inside her.

Another patient, who was approximately 29 weeks pregnant, had laminaria removed at HUP after she changed her mind about terminating her pregnancy. The doctor who performed that procedure had to know that Gosnell was breaking the law by starting to abort a 29-week fetus. And this is just the tip of the iceberg. Latosha Lewis testified that she was told by personnel in HUP’s emergency room that they treated a lot of women who came from Gosnell’s clinic with problems.

We are very troubled that almost all of the doctors who treated these women routinely failed to report a fellow physician who was so obviously endangering his patients. We understand that in emergency rooms more than one doctor may treat a patient; it might be unclear who should do the reporting. In that case, the hospital should have an established policy, which HUP apparently did not. One of the HUP doctors told us that a procedure is now in place to assure proper reporting. Among the documents turned over by the attorney for HUP was a memo to HUP personnel reminding them that they are required to report abortion complications and maternal deaths and advising them of the procedure for doing so. The memo was dated September 3, 2010, shortly before the first HUP doctor testified before the Grand jury – and 10 years after the doctors had received the same instructions in an earlier memo.

The issue, however, goes beyond simple compliance with the Abortion Control Act’s reporting requirement. Based on the evidence we heard regarding state officials’ procedures and practices, it is doubtful that reporting under that act would actually have triggered any kind of action from the state. Staloski, the DOH director in charge of abortion facilities, told us that she did not even get – or ask for – complication reports. It seems that they were treated as statistical information rather than as a means to uncover problem facilities.

We would like to believe that the dozens of complication reports doctors should have submitted to DOH would have spurred the department into action against Gosnell. However, even perfect compliance with that provision of the Abortion Control Act would not address the bigger issue of rooting out bad doctors. The doctors at HUP should have reported Gosnell to the Department of Health and to the Board of Medicine years ago. Not just because the Abortion Control Act requires them to, but also because reporting a doctor who harms his patients and breaks the law is the right thing to do.


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