This is an excerpt straight from the Grand Jury Report:
Pennsylvania is not a third-world country. There were several oversight agencies
that stumbled upon and should have shut down Kermit Gosnell long ago. But none of
them did, not even after Karnamaya Mongar’s death. In the end, Gosnell was only
caught by accident, when police raided his offices to seize evidence of his illegal
prescription selling. Once law enforcement agents went in, they couldn’t help noticing
the disgusting conditions, the dazed patients, the discarded fetuses. That is why the
complete regulatory collapse that occurred here is so inexcusable. It should have taken
only one look.
The first line of defense was the Pennsylvania Department of Health. The 9
department’s job is to audit hospitals and outpatient medical facilities, like Gosnell’s, to
make sure that they follow the rules and provide safe care. The department had contact
with the Women’s Medical Society dating back to 1979, when it first issued approval to
open an abortion clinic. It did not conduct another site review until 1989, ten years later.
Numerous violations were already apparent, but Gosnell got a pass when he promised to
fix them. Site reviews in 1992 and 1993 also noted various violations, but again failed to
ensure they were corrected.
But at least the department had been doing something up to that point, however
ineffectual. After 1993, even that pro forma effort came to an end. Not because of
administrative ennui, although there had been plenty. Instead, the Pennsylvania
Department of Health abruptly decided, for political reasons, to stop inspecting abortion
clinics at all. The politics in question were not anti-abortion, but pro. With the change of
administration from Governor Casey to Governor Ridge, officials concluded that
inspections would be “putting a barrier up to women” seeking abortions. Better to leave
clinics to do as they pleased, even though, as Gosnell proved, that meant both women and
babies would pay.
The only exception to this live-and-let-die policy was supposed to be for
complaints dumped directly on the department’s doorstep. Those, at least, would be
investigated. Except that there were complaints about Gosnell, repeatedly. Several
different attorneys, representing women injured by Gosnell, contacted the department. A
doctor from Children’s Hospital of Philadelphia hand-delivered a complaint, advising the
department that numerous patients he had referred for abortions came back from Gosnell
with the same venereal disease. The medical examiner of Delaware County informed the 10
department that Gosnell had performed an illegal abortion on a 14-year-old girl carrying
a 30-week-old baby. And the department received official notice that a woman named
Karnamaya Mongar had died at Gosnell’s hands.
Yet not one of these alarm bells – not even Mrs. Mongar’s death – prompted the
department to look at Gosnell or the Women’s Medical Society. Only after the raid
occurred, and the story hit the press, did the department choose to act. Suddenly there
were no administrative, legal, or policy barriers; within weeks an order was issued to
close the clinic. And as this grand jury investigation widened, department officials
“lawyered up,” hiring a high-priced law firm to represent them at taxpayer expense. Had
they spent as much effort on inspection as they did on attorneys, none of this would have
happened to begin with.