Excerpts from Grand Jury report about abortionist Kermit Gosnell

“Incredibly, in 2004, Department of State attorneys closed – without investigation – a case reported to the Board involving the death of 22-year-old Semika Shaw”

Editor’s note. Abortionist Kermit Gosnell is charged with eight counts of murder. “How Did This Go On So Long?” is a pivotal sections in the Grand Jury’s 261-page report. Today’s except demonstrates that multiple state agencies failed to do what should have been done years before: shut down Gosnell.


The Department of Health was not the only state agency that could and should have shut down Gosnell decades ago. The State Board of Medicine (the Board) is one of 29 boards overseen by the Department of State’s Bureau of Professional and Occupational Affairs. The Board’s attorneys had ample notice of Gosnell’s illegal and reckless abortion practices, and of the damage he had done to patients. Eight years before Karnamaya Mongar died, a former Gosnell employee told the Department of State about the illegal practice that resulted in Mrs. Mongar’s death: Gosnell had unlicensed workers anesthetizing patients when he was not at the clinic. Yet, despite receiving that report and several other serious complaints over the years, the Board took no action to suspend or revoke his license.

Attorneys for Pennsylvania’s Department of State disregarded notices that numerous patients of Gosnell were hospitalized – infected, with fetal remains still inside them; and with perforated uteruses, cervixes, and bowels. Incredibly, in 2004, Department of State attorneys closed – without investigation – a case reported to the Board involving the death of 22-year-old Semika Shaw.

Between 2002 and 2009, Board of Medicine attorneys reviewed five cases involving malpractice and other complaints against Gosnell. (The Grand Jury also received records of three older complaints – from 1983, 1990, and 1992 – one of which resulted in a reprimand.) None of the assigned attorneys, or their supervisors, suggested that the Board take action against the deviant doctor. In fact, despite serious allegations, three of the cases were closed without any investigation. The other two were investigated and then closed – without any action being taken.

Pennsylvania Department of State attorneys failed to investigate a 22-year-old patient’s death caused by Gosnell’s recklessness.

In all this inaction, one failure to investigate stands out. On October 9, 2002, the Professional Underwriters Liability Insurance Company reported to the State Board of Medicine that it had paid a $400,000 settlement to the family of Semika Shaw, the 22-year-old mother of two who died following an abortion procedure at Gosnell’s clinic in March 2000. (In January 2003, the Pennsylvania Medical Professional Liability Catastrophe Loss Fund reported to the Department of State that it had paid an additional $500,000 toward a $900,000 award to the family.) The October 9 report is logged in as “received” by the Department of State’s “Complaints Office” on December 6, 2002. The file turned over to the Grand Jury shows no further activity until over a year later – January 2, 2004 – when a one-page printout of Gosnell’s license information is stamped “received” by the complaints office.

The next action recorded in the file is a one-paragraph “Prosecution Evaluation,” dated April 29, 2004, in which Mark Greenwald, a prosecuting attorney for the Board of Medicine purportedly summarizes the case and concludes: “Prosecution not Warranted.”

Here is the paragraph:

Brief Factual Summary: The file was opened as a result of a Medical Malpractice Payment Report. The underlying malpractice case involved the death of a 22 year old female following the termination of her 5th pregnancy. Following a seemingly routine procedure on 3/1/02, the patient was taken to the ER at the University of Pennsylvania with complaints of pain and heavy bleeding. The patient underwent surgery but the surgeon was unable to locate any perforation and the patient died from infection and sepsis. Although the incident is tragic, especially in light of the age of the patient, the risk was inherent with the procedure performed by Respondent [Gosnell] and administrative action against respondent’s license is not warranted. 

RECOMMENDATION: Z-02, Prosecution not Warranted In fact, all the information in this single paragraph is taken entirely – including incorrect dates – from the insurance company’s original paragraph-long report sent to the Board in October 2002. And yet, while Greenwald included the irrelevant, but pointed, assertion that this was the patient’s fifth pregnancy that was being terminated, the Department of State prosecutor omitted from his summary the most important information that the insurance company had provided: “Autopsy report indicated perforation of cervix into uterus. Heirs alleged our insured improperly performed the termination procedure and failed to diagnose post-op uterine perforation resulting in sepsis and death.” Greenwald’s supervisor, Charles J. Hartwell, the Senior Prosecutor-in-Charge atthe Department of State’s Bureau of Professional and Occupational Affairs, purportedly reviewed Greenwald’s “evaluation” and approved it on May 14, 2004. Hartwell did so, ostensibly, knowing nothing beyond t
the bare facts that Semika Shaw died from infection and sepsis two days after Gosnell perforated her uterus and cervix during an abortion procedure. (Greenwald also omitted from his evaluation that the insurance carrier had settled the case for $900,000, the majority of which had to be disbursed by a Pennsylvania catastrophic expense fund.)

Aside from the absence of facts to support the prosecutors’ recommendation, logic, too, is missing. Abortion in the hands of decent, caring doctors is an extremely safe procedure for patients. Even if it were not, that does not mean that the death in this case was not actionable by the state. If prosecutors are going to forgo investigations every time someone dies during a medical procedure, with the excuse that death is always a possible risk with any kind of surgery, there is no point in pretending that they are investigating and prosecuting cases against doctors.