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.

How various city Health Department employees failed to report serious problems at Gosnell's clinic; and when problems were reported, that there was a failure to act on those reports.


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. 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.

The Philadelphia Health Department’s Environmental Engineering Section failed to follow through after receiving a complaint in 2003 about aborted fetuses stored in an employee refrigerator.

Years earlier, in August 2003, another branch of the city’s health department had received an anonymous complaint about Women’s Medical Society. Mandi Davis, a sanitation specialist in the environmental engineering section, wrote a memo to a colleague at the department, Ken Gruen, with a copy to then-Assistant Health Commissioner Izzat Melhem. She informed them that she had received a “rather disturbing” complaint of aborted fetuses stored in paper bags in an employee refrigerator at Gosnell’s clinic.

Davis requested that a site visit be conducted to assure that proper infectious waste handling and disposal practices were in place. Davis further instructed Gruen: “I am not expecting a ‘wild goose chase’ for aborted fetuses.” Current Philadelphia Health Commissioner Donald Schwarz testified that notations on the memo seem to indicate that a site visit was, in fact, made.

The city health department, however, could not produce any report of that site visit. Nor is there evidence that the department took any action against Gosnell for his dangerous handling of medical waste, or for his failure to have an approved infectious waste plan, as is required by the city Health Code.

A year later, Gosnell still had no approved disposal plan. On March 28, 2004, Davis sent Gosnell a letter stating that a “plan” he had submitted was “incomplete.” In fact, it was completely blank, except for the name and address of the clinic, some contact information, and an indication that it was a medical facility. On May 3, 2004, Davis sent another letter. This one was a form letter. Davis wrote:

    • Several years ago all Doctors practicing in Philadelphia received a letter from former Health Commissioner Estelle B. Richman explaining the need for the Department to have an infectious waste handling and disposal plan from your practice. The Commissioner’s letter explained the necessity for infectious waste to be properly containerized, stored, transported, and disposed in a manner to preclude any hazard to you, your staff, and patients, the community or the environment.

The letter noted that the city had never received a plan or a fee from the clinic. On May 7, 2004, a city health department inspector was sent to the clinic. His report stated that proper labels were missing from areas where waste was stored; that red bag containers for infectious waste were not lidded; that marked boxes of infectious waste were sitting on the basement floor – not raised as they should be; that red bags for pick-up were not properly stored in the basement; and that the clinic did not provide a contract with a disposal company.


Gosnell subsequently produced some more paperwork, including a copy of a contract for disposal. However, he never paid his fee. The city never approved his medical waste plan. And he never cleaned up the infectious waste. Yet five years later, he was still operating. When the Grand Jurors toured the facility in 2010, boxes of waste were still sitting on the basement floor. Gosnell still stored aborted fetuses in plastic containers in the freezer. Employees described a stench emitted by bags of fetal tissue that piled up in the clinic.

Commissioner Schwarz tried, unsatisfactorily, to explain why the city never enforced the regulations that purport to protect staff, patients, the community, and the environment. Protection of the public, according to Dr. Schwarz’s testimony, was not the real intent behind the regulations. The impetus for requiring doctors to have infectious waste plans approved by the city was not public health; it was revenue.

The city regulations required the city’s 10,000 providers to pay $100 for individuals, $250 for clinics, and $500 for institutions such as hospitals, schools, and nursing homes. But the regulations provided no guidance as to what the health department was supposed to do to enforce the plans once submitted. Dr. Schwarz related to the Grand Jury what he heard from people who were in the health department at the time:

    • The department was told, apparently, to collect the money, make sure the plan came in, get the fee, and not enforce, that is don’t take action against people but remind them. This is a revenue generating activity.

The department would only inspect or take action when there was a complaint about a provider’s infectious waste handling or disposal.

Then, according to what Dr. Schwarz was told, sometime in 2004 or 2005 – shortly after Davis sent to the clinic the form letter reminding delinquent medical providers to submit their waste plans and pay their fee – the department stopped trying to enforce the regulation against those who had not complied.

The health commissioner’s testimony might explain why the department did not pursue Gosnell for his failure to submit an adequate infectious waste plan or pay his fee. But it does not explain the department’s inaction after an inspector observed and reported Gosnell’s perilous storage and disposal of infectious waste in May 2004 (and probably in 2003, though we did not see that report).

There is no record to indicate that the health department ever checked to see if the dangerous conditions in the clinic had been remediated. It is clear from our investigation that they never were.

Philadelphia’s Health Commissioner told the Grand Jury that he is taking steps to improve the department’s procedures.

Dr. Schwarz, Philadelphia’s health commissioner since January 2008, testified twice before the Grand Jury. He expressed appropriate regret for his department’s inaction. And he personally took responsibility. We found refreshing his acknowledgement of fault, his candor, and his evident efforts, at least since being called before the Grand Jury, to find out how and why his agency failed to protect the West Philadelphia community from a notoriously dangerous doctor. But while he accepted responsibility personally, Dr. Schwarz seemed to excuse department employees who ignored the serious – and obvious – threat to public health posed by Gosnell’s clinic, and he provided feeble excuses for their inaction. We saw no evidence that the city health department had initiated an internal assessment to determine how Gosnell fell through the cracks – either in November 2009, when the Medical Examiner performed an autopsy on Mrs. Mongar’s remains, or in February 2010, after publicity surrounding the raid made the horror at 3801 Lancaster Avenue known to all.

When Dr. Schwarz testified the first time before the Grand Jury, he should have known that many department employees were well aware of Gosnell’s operation. He should have known this because professionals within the department who had information about the dangerous conditions in Gosnell’s clinic should have told him. The health commissioner assured the Grand Jury that the department is now taking steps to address problems that prevented the department from responding as it should have. He identified structural problems – and a corresponding mentality among health department employees – that contributed to the city health department’s ineffectual handling of complaints about Gosnell. The department has several very different responsibilities. The tasks it oversees range from conducting autopsies to testing for sexually transmitted diseases to dog-catching. Each function is handled by a different division with different staff.

The department’s involvement with Gosnell’s clinic touched several divisions and sections. One unit, the Division of Disease Control’s STD Control Program, tested lab samples from Gosnell’s clinic, collected data for sexually transmitted diseases, and followed up to make sure infected patients were treated. Kareema Cross testified that employees from the city health department came to the clinic to pick up specimens and blood to check for STDs. The Grand Jury received no evidence that any of these employees informed others at the health department about what they saw during their visits to the clinic.

Another part of the Division of Disease Control has responsibility for the children’s vaccine program, Matijkiw’s unit, which provides vaccines to clinics and conducts inspections. Investigating infectious waste complaints is the responsibility of the Environmental Engineering Section. The Medical Examiner, whose office is also part of the city health department, performed the autopsy on Karnamaya Mongar and examined fetal remains seized from the clinic’s freezer.

Thus, when Matijkiw, who worked in the vaccine program, discovered infectious waste in a freezer, that information was never conveyed to the environmental engineering people who could have done something about it. Dr. Schwarz recognized that, at the least, the department should have electronic records that can be shared among divisions. Employees in any unit would then be able to search for all of the department’s records on a particular provider and see the reports of other divisions.

The city health commissioner also identified a more troubling problem. Although he phrased it more diplomatically, what he was describing was an “it’s-not-in-my-job-description” mindset displayed by many department employees. When asked why Matijkiw’s superiors had not reported Gosnell to the Pennsylvania Department of State for action against his license, Dr. Schwarz tried to explain:

    • I would say that I think what happens is people have a narrowly defined job and I don’t think there has been an expectation that people would report to the state as professionals. So I think that is wrong and we are going to figure out a way to change that.

The same narrow view of their job responsibilities was displayed when Matijkiw’s superiors failed to share her report with other divisions within the city health department that could have acted.

Some of Dr. Schwarz’s explanations for health department employees’ lapses were not entirely convincing. For example, he testified that the Director of Disease Control, Dr. Caroline Johnson, told him that one reason “Jim” did not report Gosnell to the Department of State in December 2009, was that “the program people apparently knew something was happening at the site and they didn’t call the state.”

It is highly unlikely, however, that anyone at the city health department knew that something was “happening” to Gosnell in December 2009. Mrs. Mongar’s death had triggered no investigation by the state Department of Health. And there is no evidence that the Department of State was doing anything either.

Dr. Schwarz also told the Grand Jury that the city health department is limited in what it can do in response to complaints about medical providers. He gave examples of the kinds of complaints the department can do something about:

    • I could send somebody out if they have rats. I could send somebody out if someone got diarrheal disease. I could send somebody out if there was an animal, but I can’t send someone out if a person’s injured.

We understand that the city health department did not have the authority to investigate all of the things that were wrong in Gosnell’s clinic. If a patient called up to complain that they were treated badly at Women’s Medical Society, or that Gosnell was violating the Abortion Control Act in some way, the health department would not have jurisdiction. But it could certainly submit complaints to the Pennsylvania Department of State and demand that they be investigated. Furthermore, some issues were directly within the department’s purview – such as the infectious waste problems and the circumstances of Mrs. Mongar’s death.

The latter gave the Medical Examiner’s office authority to inspect the facility and to ask questions in order to investigate the manner of death. At the very least, the department’s overall mission – to protect public health in Philadelphia – ought to have prompted more responsiveness and sharing of information about the reckless doctor in West Philadelphia.

Regarding the responsibilities of his department, the city health commissioner displayed a very different attitude from that of the state officials who testified. He did not, for the most part, try to evade accountability – or work – by claiming that his agency lacked authority to do certain things. In fact, he suggested ways to fill gaps in responsibility that Gosnell fell through. He expressed an interest in increasing accountability, responsiveness, and communication among the various local and state agencies.

Even though the city lacks the authority to regulate doctors or abortion clinics, Dr. Schwarz recognized that the Department of Public Health should have a system in place, which it now does not have, to handle calls made by Philadelphia residents to complain about Philadelphia medical providers. When asked if the health department had ever received calls about Gosnell, the commissioner frankly acknowledged: “if someone called, I’m embarrassed to say, I don’t know what would happen.”

Dr. Schwarz testified that he sees a role for the city health department in cataloging complaints and helping patients of Philadelphia doctors refer complaints to the proper authorities. Complaints about individual doctors would be forwarded to the Department of State, which licenses doctors and is responsible for investigating complaints and imposing sanctions. Complaints about health care facilities, such as Gosnell’s clinic, would be forwarded to the state Department of Health, which has the authority and duty to license, inspect, and sanction them.

The health commissioner told the Grand Jury that his department is already considering ways to help callers register their complaints with the proper authority. The process, he said, should include a response to the individual who filed the complaint, letting them know that it was received and what is being done about it. Dr. Schwarz suggested the health department might fill another gap by conducting routine sanitation and safety inspections of doctors’ offices and clinics. Neither the state nor the city currently inspects them. The city health department does inspect some institutions, such as day care centers, prisons, and schools. It inspects the food services at hospitals, though not the hospitals themselves. Dr. Schwarz acknowledged that the city health department probably could step into that role, although not without hiring more inspectors.

The Grand Jurors hope the health commissioner follows through on his suggestions. We also wish state officials showed as much eagerness to address the bureaucratic deficiencies and neglect that, for decades, allowed someone like Gosnell to wantonly break laws, harm and endanger women, and kill viable babies in the secure knowledge that no official overseer would intervene to stop him.