I am using the Grand Jury Report on the crimes of Philadelphia abortionist Kermit Gosnell as the basis of this Wiki. I will add material to support my contention that though Gosnell is beyond the pale, this is mainly in the way he combined and refined aspects of the ghoulish and callous disregard for humanity often seen in abortionists. He was hardly a pioneer.

In order to distinguish between my own writings, and those of the Grand Jury, I will use a different font that makes the Grand Jury Report appear to be typed.



Worth special mention is Janice Staloski of the Pennsylvania Department of Health, who personally participated in the 1992 site visit, but decided to let Gosnell slide on the violations that were already evident then. She eventually rose to become director of the division that was supposed to regulate abortion providers, but never looked at Gosnell despite specific complaints from lawyers, a doctor, and a medical examiner.

Janice Staloski with Sara Telencio performed the March 1992 DOH inspection. There were multiple problems with the review, including that there were no nurses monitoring patients recovering from abortion, and the inspectors left blank whole sections of their report on anesthesia and post-operative care; yet they concluded that there were "no deficiencies."

Ten years later, Janice Staloski was the Director of DOH's Division of Home Health (the unit that oversees the quality of care in abortion clinics). That year, an attorney representing Semika Shaw requested copies of inspection reports, and Staloski replied that there had been no inspections done since 1993 because there had been no complaints in that time. Yet in 1996, another attorney representing a different patient had informed the previous Director "that his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell's negligence." The complaint report was documented.

Dr. Donald Schwarz, a respected pediatric doctor, hand-delivered a complaint about Dr. Gosnell between 1996-1997, after he realized that patients who had abortions at Women's Medical Society were being infected with trichomoniasis, a sexually transmitted parasite. No inspection was made, and the complaint was not included in response to the subpoena requesting all complaints relating to Gosnell's clinic.

The Grand Jury was unsure whether Janice Staloski and Kenneth Brody, who should have been aware of Dr. Shwarz's complaint, 1) remembered it but chose to exclude it from their testimony, 2) did not even remember this, despite its seriousness, or 3) the secretary of health never forwarded it on for action. The Grand Jury said it didn't know which was the worst of those three options.

Additionally, Staloski received two inquiries from two different attorneys in January and February 2002 asking for information concerning the clinic. The Grand Jury said, "Surely these two inquiries in 2002 should have alerted Staloski that there were complaints from at least two people about the clinic, complaints serious enough to warrant civil attorneys’ involvement." But she did not inspect the clinic, even though it had been 9 years since the last site review.

Staloski blamed the decision to abandon supposedly annual inspections of abortion clinics on DOH lawyers, who, she said, changed their legal opinions and advice to suit the policy preferences of different governors. Under Governor Robert Casey, she said, the department inspected abortion facilities annually. Yet, when Governor Tom Ridge came in, the attorneys interpreted the same regulations that had permitted annual inspections for years to no longer authorize those inspections. Then, only complaint-driven inspections supposedly were authorized. Staloski said that DOH’s policy during Governor Ridge’s administration was motivated by a desire not to be “putting a barrier up to women” seeking abortions.

Brody confirmed some of what Staloski told the Grand Jury....


Nevertheless, the position of DOH remained the same after Edward Rendell became governor... The department continued its do-nothing policy until 2010, when media attention surrounding the raid of the Gosnell clinic exposed the results of years of hands-off “oversight.” Now, once again, the regulations, which have never been modified, apparently allow for regular inspections. This is, and always was, the correct position.


Moreover, even if Staloski was instructed not to conduct regular, annual inspections, that does not explain why she failed to order inspections when complaints were received. It is clear to us that she was made aware, numerous times, that serious incidents had occurred at Gosnell’s clinic. These incidents, which evidenced alarming as well as illegal long-standing patterns of behavior, warranted investigation. Yet, in all the years she worked at the department, Staloski never ordered even one inspection....


On November 24, 2009, Gosnell sent a fax to the department, followed by a letter addressed to Staloski, notifying DOH that Karnamaya Mongar had died following an abortion at his clinic.


Staloski was no longer the Director of the Division of Home Health, having been promoted in 2007 to head the Bureau of Community Licensure and Certification. Cynthia Boyne was Director at that time. Darlene Augustine, RN and healthy quality administrator received the fax, notified Boyne, and asked for her to send out investigators.

Boyne did not give her approval. Instead, she went to the bureau director, Staloski, to discuss the matter. Augustine explained that abortion clinics were treated differently from other medical facilities because Staloski had for years overseen the department’s handling of complaints and inspections – or lack of inspections – relating to abortion clinics. Staloski, according to Augustine, was “the ultimate decision-maker” with respect to whether DOH would conduct an inspection or investigation. Augustine testified that neither Boyne nor Staloski ever gave her approval to conduct the investigation that she thought was appropriate.


Boyne blamed Staloski. She said that her boss told her that DOH did not have the authority to investigate Mrs. Mongar’s death. Staloski apparently reached this decision on her own, without ever consulting Brody, the legal counsel. Staloski, according to Boyne, was only interested in making sure that Gosnell filed an on-line report in accordance with a 2002 law, the Medical Care Availability and Reduction of Error (MCARE) Act. That law requires health care facilities to report serious events, including deaths to DOH. 40 P.S. §313.


Staloski’s plan, Boyne said, was to then charge Gosnell with failing to file the report in a timely and proper manner. This is absurd, and Boyne should not have accepted such a ridiculous idea. Gosnell had reported Mrs. Mongar’s death to DOH on November 24, 2009. While this was three or fours days late, and the notification came by fax and letter rather than computer, it is preposterous to think that Staloski, who had ignored two deaths and other serious injuries at the clinic, would take action against a doctor for filing a report three days late. Staloski was absolutely wrong about DOH’s lack of authority to investigate Mrs. Mongar’s death.


Not only was a probe into Mrs. Mongar’s death authorized and appropriate under the Abortion Control Act, it was required under the MCARE law. 40 P.S. §306. Yet DOH did not investigate. Staloski told the Grand Jury that she remembered reviewing with Boyne the letter in which Gosnell notified DOH of Mrs. Mongar’s death. Staloski said that it was really Boyne’s responsibility to order an investigation, but acknowledged that she, as the bureau director, also failed to do so. Instead of conducting an investigation, Staloski and Boyne concerned themselves with badgering Gosnell to re-notify them of Mrs. Mongar’s death.


Bureau Director Staloski, in fact, readily acknowledged many deficiencies in DOH’s, and her own, oversight of abortion facilities. But her dismissive demeanor indicated to us that she did not really understand – or care about – the devastating impact that the department’s neglect had had on the women whom Gosnell treated in his filthy, dangerous clinic.


Staloski excused the DOH practices that enabled Gosnell to operate in the manner that killed Ms. Shaw, Mrs. Mongar, and untold numbers of babies. She simply said the abortion regulations – written by DOH – do not require DOH to inspect abortion clinics.


When DOH inspectors finally entered Gosnell’s clinic in February 2010, not at Staloski’s direction but at the urging of law enforcement, Staloski seemed more annoyed than appalled or embarrassed. On the morning after the raid, she received a copy of an email that Boyne wrote to Brody the night of the raid. Boyne reported to the department’s senior counsel that, at 12:45 a.m., she had told the Department of Health staff members at the clinic to “wrap it up and secure lodging in the interest of their safety.” Boyne told Brody that the “staff walked into a very difficult setup.” She complained that a representative of the District Attorney’s Office was “badgering” DOH staff to shut down the facility immediately. Boyne was seeking Brody’s legal guidance.

Staloski’s response to Boyne’s email was: “I’d say we were used.” Boyne’s reply: “Bingo.”


Staloksi, the woman most directly responsible for the department’s oversight of abortion facilities, told the Grand Jury: “I haven’t been in any facilities in probably – in an abortion facility in many, many years.” The citizens of Pennsylvania deserve far better from those charged with protecting public health and safety.

~*~


On hearing of Semika Shaw’s death, for example, Janice Staloski, the director of home health who had responsibility for overseeing abortion clinics, did not order an investigation or even an inspection of the clinic. She failed to perform even the simple task of checking to see if Gosnell had reported her death as the Abortion Control Act mandated. She did refer Ms. Shaw’s attorney to the Department of State.


More to the point, Bastian, like Staloski, did not order an investigation or inspection of the clinic that it was his duty to monitor. Even when Ms. Shaw’s heirs were awarded $900,000, and when the 19-year-old recovered $500,000, no one at DOH seemed to think it was worth taking a look at the clinic....


Even after learning of Ms. Shaw’s death from her estate’s attorney, Staloski ignored the information....


Conversely, Staloski, on learning of Ms. Shaw’s lawsuit from the plaintiff’s attorneys, should have checked with the Department of State to make sure that Gosnell had reported the suit as mandated by the MCARE law.


As it happened, none of the state officials who testified before the Grand Jury shared or requested information that was necessary to carry out their duties. Frankly, their demeanor during their testimony indicated that they were content to use their selfimposed lack of knowledge as an excuse for inaction. Proper supervision and accountability for performance, in addition to new procedures, clearly are required.


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.