“Other than assuring that vaccines were not placed in the same freezer, the city health department showed no concern about the stored fetuses or the dripping frozen blood observed by Matijkiw.”

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.”


Marcella Choung was not the only person to report Gosnell’s appalling medical practice to health officials. An employee of the Philadelphia Department of Public Health alerted her bosses – twice – that things were seriously wrong at Gosnell’s clinic. The last time she did so was one month before Karnamaya Mongar died [in 2009]. Records produced by the city department reveal that employees in at least two different divisions within the department missed red flags that should have led to investigation and action.

Supervisors in the Division of Disease Control ignored a nurse’s disturbing report about conditions in Gosnell’s clinic in 2008 and 2009.

The City of Philadelphia employee who did notice and report the abysmal conditions she observed at Gosnell’s clinic was a registered nurse named Lori Matijkiw. Matijkiw conducted what the Health Department calls an “AFIX” visit, or vaccine inspection, in July 2008. Using the name “Family Medical Society,” Gosnell purported to be a provider of children’s vaccines under a program administered by the Philadelphia Health Department’s Division of Disease Control. The doctor’s history with the program, however, was rocky. Emails going back to August 2001 reveal that he was suspended from the program repeatedly for failing to maintain logs and for storing vaccines in filthy, unsuitable refrigerators, and at improper temperatures.

Health department employees who visited the clinic between 2001 and 2007 recorded that they dealt with “Drs.” O’Neill and Massof, but never Gosnell. These inspectors noted problems with the refrigerator, the clinic’s record-keeping, and expired vaccines. They were apparently oblivious, however, to other obvious deficiencies that did not relate directly to vaccines. On July 16, 2008, at 1:30 p.m., Matijkiw made a vaccine inspection visit to Gosnell’s clinic. Unlike the inspectors before her, she did not simply stick to her narrow, assigned task of inspecting vaccines and their storage units. She took seriously her broader duty to protect public health. Following her visit to Gosnell’s facility, she reported on a multitude of deficiencies she found.

In an email to her superiors at the Philadelphia Department of Public Health – whom we have identified as Program Manager Lisa Morgan and Medical Director Dr. Barbara Watson – Matijkiw reported that she had trouble even scheduling an appointment. No one answered the phone at the clinic, and when they finally did, they told her that “Dr. Massof” was on leave. After she finally scheduled an appointment, neither Gosnell nor the office manager was at the facility when she arrived. The two women who were there, she wrote, were “clueless.” While Matijkiw waited for the women to try to contact Gosnell, she noticed signs taped to the front desk. One was a price list for abortions detailing the costs for different gestational ages, with a price list for four different levels of anesthesia [Appendix C]. A third sign announced: “If you have the pre-procedure blood tests and work up done, and change your mind, you are still responsible for the costs of the tests.” Matijkiw wrote down everything she observed.

She noted that the office was “not clean at all, and many areas of the office smell like urine.” She reported a “dark layer of dust” on the baseboards and described the “enormous” fish tanks, filled with murky water. In the refrigerator, she found expired vaccines – one with an expiration date of March 2006, another 2005. The temperature log, which was supposed to record the refrigerator temperature every day, had not been marked since the second day of June – a month and a half earlier. On top of the refrigerator, she found a stack of temperature logs, already filled out, showing readings twice a day, with no initials, time, or month.

Matijkiw wrote that Tina Baldwin showed her to a freezer in a “lab” (quotation marks are in the original email) on the second floor. Inside she found “3-4 large plastic containers with blood-colored frozen contents, wrapped in blue chux.” She described a “red fluid spilled/frozen on the floor of the freezer.” Chicken pox vaccines were stored in an ice tray above the containers of bloody fetuses.

The clinic staff told Matijkiw that “Dr. Massof” had left abruptly in June and that Gosnell was unfamiliar with the program. When Matijkiw asked to see files showing vaccines administered, the staff told her they had none. She reported to her bosses that she looked up Gosnell on the state website and found that he had been disciplined in the past.

Based on Matijkiw’s report, the city health department suspended Family Medical Society – once again – from the vaccine program, but took no further action. In fact, a little over a year later, the department was considering re-enrolling the clinic in the program. A note by one employee in August 2009 recorded: “Site was told they need to purchase a new unit to store their vaccines completely SEPARATE from all other medical products” – an apparent reference to the containers filled with fetuses. Other than assuring that vaccines were not placed in the same freezer, the city health department showed no concern about the stored fetuses or the dripping frozen blood observed by Matijkiw.

On October 7, 2009, Matijkiw returned to the clinic. Again she wrote a scathing report, addressed, again, to her supervisor, Lisa Morgan. In it Matijkiw described a two hour meeting with “(Dr.) O’Neill” (the parentheses were in her original email). During the visit, Matijkiw learned that O’Neill had no understanding of the vaccine program. O’Neill reportedly believed that the free children’s vaccines could be given to adult patients and to those with private insurance. Matijkiw noticed that one of the free vaccines was given to Gosnell’s daughter. In addition, Matijkiw noticed that the clinic listed 20 children on Keystone Mercy, a Medicaid health plan. Matijkiw wrote that three of the “children” were almost 19 years old, and one had private insurance through Aetna. She wondered if any of them had ever been in the clinic. She also said that O’Neill was improperly trying to count abortion patients as vaccination patients.

In response to questioning by Matijkiw, O’Neill admitted that she was not licensed in Pennsylvania. She falsely claimed to have had a Delaware license, which she said she let lapse. When Matijkiw asked who in the practice treated children, O’Neill replied: “They don’t come in.” Yet Gosnell and O’Neill claimed to be providers of children’s vaccines.

Again Matijkiw documented the dirtiness of the facility, the murky fish and turtle tanks, the expired vaccines, and the lack of temperature logs. In addition, this time, she reported seeing patients being escorted into the procedure area when Gosnell was not in the clinic. Matijkiw concluded her report to her boss: “If Dr. Gosnell was out of the office and [O’Neill] had to call the other physician’s assistant on his cell phone and leave a message for his MA#, why were patients in the procedure area?” Matijkiw’s email to Morgan should have resulted in immediate action. Just like her report the year before should have triggered a response. If nothing else, Matijkiw’s supervisors should have passed her information about the unsanitary conditions and the fetuses in the freezer to another division within the city health department with jurisdiction over such matters.

They should also have reported Gosnell and O’Neill to the Department of State’s Board of Medicine, based on the evidence apparent to Matijkiw that patients were being treated in Gosnell’s absence and that O’Neill was practicing without a license. Yet the city health department did nothing.

A month after Matijkiw’s second visit to the clinic, Mrs. Mongar died. A month after that, in December 2009, a notation in Philadelphia Department of Public Health records stated: “Site will not be enrolled in [the Vaccine for Children program] after Matijkiw’s visits. We will pick up any wasted vaccines in January. Jim is reporting Dr. to state licensing.” But “Jim,” an apparent reference to Immunization Program Director Jim Lutz, never did report Gosnell. And no one else at the city health department did either.