Editor’s note. Abortionist Kermit Gosnell is charged with eight counts of murder. In the section “How Did This Go On So Long?” the report demonstrates conclusively that agencies had been aware for years of all the violations the Grand Jury documents in its 261-page report but that departmental attorneys “did nothing to investigate the mayhem at Gosnell’s clinic.”
The department’s prosecuting attorneys never put the pieces together about Gosnell because they did not bother to consider prior complaints. … Had any prosecutors properly investigated, perhaps they would have understood the magnitude of Gosnell’s recklessness.
The Grand Jury is convinced – based on the number of state prosecutors who failed to take action against Gosnell, on the fact that the prosecutors’ supervisors uniformly approved recommendations not to take action, and on the testimony of Prosecuting Attorney Ruiz – that the problem does not lie just with the individual attorneys.
There are clearly problems with procedures, training, management, and motivation within the Department of State’s Bureau of Professional and Occupational Affairs. It seems obvious that, in order to evaluate a complaint against a doctor, a prosecutor should look at the doctor’s history, including other complaints, lawsuits, and their outcomes. Yet the various prosecuting attorneys who handled the complaints against Gosnell seemed either unaware of or unconcerned about the content – or even the existence – of previous complaints. Ruiz, for example, when asked how many complaints against the doctor had come in, said that the department had been notified of only two lawsuits involving Gosnell.
These, he said, were Alice’s in 2005 and Dana Haynes’s in 2008. He also acknowledged that the Board had received Marcella Choung’s complaint. Ruiz’s supervisor, Kerry Maloney, apparently shared the same misunderstanding regarding the number of complaints. Maloney is quoted in a March 3, 2010, Philadelphia Inquirer article, stating: “In my experience, two cases in eight years is not a lot.” Both Ruiz and Maloney seemed to be unaware of the other complaints that Department of State attorneys had reviewed since 2002, including the case of Semika Shaw, whose death was reported to the department by Gosnell’s insurance carrier, pursuant to the MCARE law.
The Department of State turned over seven complaint files on Gosnell to the Grand Jury. (One was from 1990, and another from 1992; no file was produced for an eighth complaint – an allegation from 1983 that Gosnell had no malpractice insurance.) Our review of the files showed that some prosecutors were aware of all previous complaints against Gosnell. These files included printouts listing the file numbers for the earlier complaints. Clearly, Greenwald, who handled Semika Shaw’s case, also knew of Marcella Choung’s allegations – he was assigned to that case as well – though this did not stop him from closing the Shaw case without investigation. Other prosecutors, however, seem not to have even looked for prior complaints. Ruiz’s account of “prior history” includes only the complaint from 1992, for which Gosnell received a reprimand. Grubb’s file shows that, when he handled the 2006 complaint from Alice, he knew there was another open complaint at the time, but he chose to ignore it.
The department’s prosecuting attorneys never put the pieces together about Gosnell because they did not bother to consider prior complaints. Had every subsequent prosecutor been aware of Marcella Choung’s complaint, perhaps at least one of them would have looked more carefully at the case in front of him and recognized that the injuries inflicted by Gosnell were not caused by temporary negligence. Had any prosecutors properly investigated, perhaps they would have understood the magnitude of Gosnell’s recklessness. When one prosecutor gets a complaint that the doctor has no insurance, and another prosecutor has been looking into a similar complaint for over two years, some form of coordination or collaboration should be required to ensure proper action is taken.
The testimony of the one prosecutor who appeared before the Grand Jury revealed a lack of knowledge about certain aspects of state law and Department of State procedures that indicates a lack of training. For example, Ruiz said he was unaware that insurance companies had to report medical liability settlements to the department, even though Gosnell’s file contained just such a report relating to Semika Shaw. This is significant because it is an obvious way for state officials to check to make sure that doctors are reporting all of the lawsuits filed against them as required by MCARE. Had anyone cross-checked, it would have been discovered that Gosnell did not report Ms. Shaw’s lawsuit to the Department of State, or her death to the Department of Health. This lack of training is apparent in all of the departmental attorneys who did nothing to investigate the mayhem at Gosnell’s clinic.