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.

List of all the charges that the grand jury recommended that Gosnell and his staff be charged with, and the detailed reasoning for those charges. See the Table of Contents below and to the right to easily navigate between sections.

Section VII: Criminal Charges

Gosnell and his staff showed consistent disregard not only for the health and safety of their patients, but also for the laws of Pennsylvania. After reviewing extensive and compelling evidence of criminal wrongdoing at the clinic, the Grand Jury has issued a presentment recommending the prosecution of Gosnell and members of his staff for criminal offenses including:

• Murder of Karnamaya Mongar
• Murders of babies born alive
• Violations of the Controlled Substances Act
• Hindering, Obstruction, and Tampering
• Perjury
• Illegal late-term abortions
• Violations of the Abortion Control Act
• Violations of the Controlled Substances Act
• Abuse of Corpse
• Theft by Deception
• Conspiracy
• Corrupt Organization
• Corruption of Minors

Specifically, the Grand Jury recommends that the Philadelphia District Attorney’s Office bring the following criminal charges:

• Murder in the death of Karnamaya Mongar

Gosnell’s contempt for the law and his patients cost Karnamaya Mongar her life. Her death was the direct result of deliberate and dangerous conduct by Gosnell and his staff. They consciously disregarded the unjustifiable risk that their conduct would cause death.

Under Pennsylvania law, the voluntary commission of an act that results in the victim’s death, where the offender acts with legal malice, express or implied, is murder, even if the resulting death is unintentional or accidental. “Malice” is a legal term meaning, for example, hardness of heart, wanton conduct, recklessness of consequences, or a mind regardless of social duty. If someone consciously disregards an unjustified and extremely high risk that his or her conduct might cause death or serious bodily injury, he or she has acted with malice, and may be convicted of murder.

Gosnell, Williams, and West acted with malice when they consciously disregarded the extremely high risk that administering high doses of Demerol to Karnamaya Mongar could kill her. The overmedication of Mrs. Mongar was more than careless. It was consistent with the routine practice at Gosnell’s clinic of keeping patients subdued and sedated by giving them whatever medication Gosnell’s workers deemed appropriate. Gosnell set up his practice this way, and delegated to his unlicensed and unsupervised staff the responsibility to inject patients with potent drugs. Despite warnings from his other employees about Williams and West and their overmedication of patients, and even though the doctor knew that neither West nor Williams was trained, authorized, or licensed to dole out controlled substances, Gosnell recklessly allowed them to drug patients.

West told the FBI that she and Williams mixed medications for various levels of anesthesia and administered these drug mixtures to patients. According to Ashley Baldwin, Williams would medicate patients “whenever Sherry told her to.” West also medicated patients “a lot,” Baldwin said. When West and Williams called Gosnell on November 19, 2009, reporting that Mrs. Mongar was in pain, Gosnell directed them to “med her up.”

Demerol is a drug known to have cardiac and respiratory side effects. Its sedating effect is enhanced when it is given with other medications such as promethazine, another ingredient in Gosnell’s routine sedation formula. This “synergistic effect” can depress respiration. But these hazards were of no concern to Gosnell.

The Philadelphia medical examiner found that the cause of Mrs. Mongar’s death was “acute anoxic encephalopathy following resuscitation from cardiopulmonary arrest due to meperidine intoxication.” In other words, despite resuscitative efforts, her brain ceased to function after her heart and breathing stopped as a result of the overdose of Demerol. The medical examiner concluded that the manner of death was homicide.

Another expert, the Delaware County medical examiner, concurred, explaining that to give potent drugs “willy-nilly” – without tailoring the administration of the drugs to the patient, without monitoring the patient, and without the doctor even being on the premises – was grossly negligent, reckless, and, in his opinion, homicide.

The gross negligence, recklessness, and disregard of life-threatening risks displayed by Gosnell and his staff cost Karnamaya Mongar her life. Their actions demonstrated a hardness of heart, wanton conduct, recklessness of consequences, and a mind regardless of social duty, establishing legal malice. We recommend that Kermit Gosnell, Lynda Williams, and Sherry West be charged with third-degree murder, pursuant to 18 Pa.C.S. § 2502(c).

• Drug delivery resulting in the death of Karnamaya Mongar.

The evidence also supports a murder charge for drug delivery resulting in death.

    • A person commits murder of the third degree who administers, dispenses, delivers, gives, [or] prescribes … any controlled substances … in violation of section 13(a)(14) or (30) of the … Controlled Substance, Drug, Device, and Cosmetic Act, and another person dies as a result of using the substance.

18 Pa.C.S. § 2506. The Controlled Substances Act prohibits delivery of a controlled substance such as Demerol by any unlicensed practitioner, or the dispensing of any controlled substance by or at the direction of a practitioner other than “in accordance with treatment principles accepted by a responsible segment of the medical profession.” 35 P.S. §§ 780-113(a)(14), (30).

Gosnell, Williams, and West violated these provisions when they gave Mrs. Mongar the excessive medication that killed her. We recommend prosecuting Kermit Gosnell, Lynda Williams, and Sherry West for Drug Delivery Resulting in Death.

West and Williams were not remotely qualified to tend to patients, much less to be injecting narcotics into patients, yet this is precisely what Gosnell had them do, regularly and without any medical supervision, in violation of the law. The administration of high doses of Demerol to anesthetize the diminutive Mrs. Mongar was well outside any “treatment principles accepted by a responsible segment of the medical profession.”

Responsible medical care also requires sedated patients to be monitored. This is particularly important, and indeed obvious, when a drug has known cardiac and respiratory side effects, as Demerol does. The anesthesiology expert testified that the standard of care for ambulatory surgical facilities and outpatient clinics requires monitoring of no less than blood pressure, heart rate and rhythm, and breathing, by electrocardiogram and pulse oximeter. Sedating without monitoring, the expert said, “is offensive to me as a physician.” In Mrs. Mongar’s case, it constituted murder.

Murder of babies born alive.

As a result of Gosnell’s regular practice of terminating pregnancies beyond the 24-week legal limit, viable babies were often born alive at his clinic. And when they were, he would kill them, by severing their spines with scissors. He told his staff that this barbaric conduct was standard medical practice. It was not. It was criminal behavior.

A medical expert with 43 years of experience in performing abortions was appalled. This expert told us, “I’ve never heard of it [cutting the spinal cord] being done during an abortion.” The expert explained, “I’m not aware of any basis within which a physician would cut the neck of a fetus.” Describing the practice as “bizarre,” he said, “it would be the same thing as putting a pillow over the baby’s face, that the intention would be to kill the baby.”

Although no one could place an exact number on the instances, Gosnell’s staff testified that killing large, late-term babies who had been observed breathing and moving was a regular occurrence. Based on seven identifiable victims, we recommend murder charges against Kermit Gosnell, Lynda Williams, Adrienne Moton, and Steven Massof. We also recommend that Gosnell, Williams, Moton, and Massof be charged with conspiracy to commit murder.

In addition, Gosnell should be charged with three counts of solicitation to commit murder. We also recommend charges of conspiracy to commit murder generally, with respect to the standard practice, testified to by employees who observed it countless times, of killing viable babies born alive.

Kareema Cross and Ashley Baldwin testified about one baby, whom we are calling “Baby Boy A,” born in July 2008. We recommend that Kermit Gosnell be charged with murder for killing Baby Boy A. According to an ultrasound, the 17-year-old mother, “Sue,” was 29.4 weeks pregnant. Gosnell induced labor and sedated the mother, who delivered a baby boy. Cross saw Baby Boy A breathe and move. Cross told us the baby was 18 to 19 inches long and nearly the size of her own newborn daughter, who was six pounds, six ounces at birth. Even Gosnell commented on Baby Boy A’s size, joking “this baby is big enough to walk around with me or walk me to the bus stop.”

Cross testified that she saw “the doctor just slit the neck” and place the remains in a plastic shoebox for disposal. Employees Adrienne Moton and Ashley Baldwin also were present. All three workers were so startled by Baby Boy A’s size that they each took a photograph. Cross explained,

    • Q. Why did you all take a photograph of this baby?
    • A. Because it was big and it was wrong and we knew it. We knew something was wrong.

Adrienne Moton gave an FBI agent consent to search her cell phone for the photograph that she took. The FBI lab was able to find the picture on her cell phone; we saw this photograph, introduced as Exhibit 57. Moton told FBI Agent Jason Huff that she took this picture because Baby Boy A was born alive.

A neonatologist viewed Exhibit 57, the photograph of Baby Boy A. Based on his size, hairline, muscle mass, subcutaneous tissue, well-developed scrotum, and other characteristics, the neonatologist opined that the gestational age was at least 32 weeks.

The Grand Jury was able to identify this baby because Kareema Cross remembered the mother, “Sue,” who came in with her great-aunt. The aunt testified before the Grand Jury that Gosnell demanded an extra $1,000 because Sue’s pregnancy was so advanced.

We recommend a murder charge against Kermit Gosnell in the death of “Baby Boy B,” whose frozen remains were discovered during the February 2010 raid.

The search team discovered red biohazard bags containing the remains of 47 fetuses,which were turned over to the Philadelphia medical examiner. One was ”Baby Boy B,” found frozen in a plastic spring-water jug (labeled by the medical examiner as 1B). The medical examiner determined that this baby had a gestational age of at least 28 weeks.

According to the medical examiner’s report and testimony, the baby was viable and intact, except for a “surgical defect” at the base of his neck.

We recommend murder and conspiracy charges against Kermit Gosnell and Lynda Williams for the murder committed by Lynda Williams in 2006 or 2007 of “Baby C.” Cross testified that she saw Williams cut the neck of the infant we have named Baby C, who had been moving and breathing for approximately 20 minutes.

Gosnell had delivered the baby and put it on a counter while he suctioned the placenta from the mother. Williams called Cross over to look at the baby because it was breathing and moving its arms when Williams pulled on them. After touching the baby, Williams slit its neck.

When asked why Williams had killed the baby, Cross answered:

    • Because the baby, I guess, because the baby was moving and breathing. And she see Dr. Gosnell do it so many times, I guess she felt, you know, she can do it. It’s okay.

The evidence of an intentional killing and an implicit agreement to kill a newborn supports charges of murder and criminal conspiracy against Williams and Gosnell for killing Baby C.

There is sufficient evidence to charge Adrienne Moton and Kermit Gosnell with murder and conspiracy in the death of “Baby D.” Kareema Cross testified that a woman had delivered this large baby into a toilet before Gosnell arrived at work for the night. Cross said that the baby was moving and looked like it was swimming. Moton reached into the toilet, got the baby out, and cut its neck.

Cross said the baby was between 10 and 15 inches long and had a head the size of a “big pancake.” Cross could not pinpoint the year that this happened, but testified that this killing occurred while Steven Massof was still working at the clinic. (Massof left in July 2008.) Moton herself admitted to Agent Huff that she had severed the spinal cords of living babies. According to her statement, Gosnell trained and instructed her to do this.

The charts that the neonatology expert provided us indicate that the size of Baby D was consistent with viability.

This evidence of an intentional killing by Moton and an implicit agreement with Gosnell to kill babies as he instructed supports the charges of murder and criminal conspiracy against Moton and Gosnell for killing Baby D. We recommend charging Kermit Gosnell with Criminal Solicitation of Adrienne Moton.

We recommend that a murder charge be filed against Kermit Gosnell for the murder of “Baby E,” a baby that Ashley Baldwin heard crying before Gosnell killed it.

Ashley testified that she heard the baby cry in the large procedure room, the one used for later-term abortions, and saw the baby moving. She said Lynda Williams summoned Dr. Gosnell, who then went into the procedure room where the baby was.

Kareema Cross testified that Ashley had called her over, and that she heard this baby “whine” once while Dr. Gosnell was alone in the procedure room with the baby. Ashley confirmed that Gosnell was the only person in the room with Baby E. When he came out of the room, the baby was dead. Gosnell put the baby’s remains in a waste bin. Ashley saw an incision in Baby’s E’s neck.

We recommend murder and conspiracy charges against Kermit Gosnell and Steven Massof for killing “Baby F.” Massof testified that he was assisting Gosnell with an abortion when he saw the baby’s leg “jerk and move.” The neonatology expert testified about the significance of movement in determining gestational age, and explained that the muscle tone and neurological development for a baby to pull back a limb exist “definitely in the bigger preemies like above, you know, 25, 26, 27 weekers.”

After Massof observed this movement of Baby F outside the mother’s womb, Gosnell severed the baby’s spine with scissors. We believe that the evidence supports charges of murder and conspiracy against Gosnell and Massof.

Steven Massof also testified about the killing of a baby whom he observed breathing. We refer to this baby as “Baby G.” Massof said that he was again helping Gosnell in the large procedure room when he saw the fully expelled baby exhibit what he called “a respiratory excursion,” meaning a breath. According to Massof, Gosnell then “snipped the cervical part of the vertebra.” The evidence supports charges of murder and conspiracy against Kermit Gosnell and Steven Massof for the killing of Baby G.

These seven murders were not isolated incidents. Severing the spinal cords of moving, breathing babies outside their mothers’ wombs was, according to Massof, “standard procedure.” Gosnell encouraged his staff to kill babies born alive; Lynda Williams, Adrienne Moton, and Steven Massof all followed his barbaric example. Massof testified that Gosnell taught him and showed the scissors-in-the-neck technique to “ensure fetal demise.” The evidence warrants three charges of criminal solicitation against Kermit Gosnell.

Gosnell’s students parroted his grisly techniques. Massof himself admitted to us that, of the many spinal cords he cut, there were about 100 instances where he did so after seeing a breath or some sign of life. The shocking regularity of killing babies who were born alive, who moved and breathed, as testified to by Gosnell’s employees, demonstrates that these murders were intentional and collaborative. In addition to the specific murder charges identified above, we recommend that Kermit Gosnell, Lynda Williams, Sherry West, Adrienne Moton, and Steven Massof be charged with conspiracy to commit murder.


Failure to provide care to any baby born alive during an abortion or premature delivery constitutes the crime of infanticide under Pennsylvania law. 18 Pa.C.S. § 3212. The legal duty to provide care extends to any newborn “born alive” where such care is “commonly and customarily provided . . . under similar conditions and circumstances.”

According to the neonatology and obstetric experts that we consulted, care is routinely provided, and resuscitation is routinely attempted, at 22 or 23 weeks.

At Gosnell’s clinic, no steps were ever taken to attend to these babies, according to his employees. Every time that Gosnell failed to provide appropriate care and treatment to a child born alive, he committed infanticide, under Pa.C.S. § 3212. We were surprised to learn, however, that infanticide is subject to a two-year statute of limitations.

That means we are unable to recommend charges for any of the many instances of infanticide that we heard about that occurred before January 2009. Instead, based on the following specific instances, we recommend that Kermit Gosnell be charged with two counts of infanticide:

    • • A 28-week-old male, found frozen in container 1B with a surgical incision at the base of the neck, discovered in the February 2010 raid, and determined by the medical examiner to have been viable.

    • • A 26-week-old female also found in the February 2010 raid, determined by the medical examiner to have been viable. Her frozen remains were in a distilled water container labeled by the medical examiner as 1C.

• Violations of the Controlled Substances Act in relation to the death of Karnamaya Mongar

Violations of the Controlled Substances Act, in addition to forming the basis for murder charges, constitute separate criminal offenses. Neither Williams nor West was licensed to dispense Demerol, yet Williams injected Karnamaya Mongar multiple times, and West assisted her. West told the Department of Health that she called Gosnell, and that he directed her and Williams, in his absence, to give Mrs. Mongar more medication, including Demerol.

As Gosnell, West, and Williams all knew, neither Williams nor West was licensed to dispense any controlled substance. And, as discussed above, the dispensing of excessive amounts of Demerol to Mrs. Mongar was not remotely consistent with accepted or reasonable medical practice. We recommend that Kermit Gosnell, Lynda Williams, and Sherry West be charged with felony drug offense under the Controlled Substances Act.

Also, because Gosnell, Williams, and West together agreed to commit these violations of drug laws, and acted in concert with their criminal objective being the unlawful dispensing of Demerol, we recommend that Kermit Gosnell, Lynda Williams, and Sherry West be charged with conspiracy. And because Gosnell instructed Williams and West to drug Mrs. Mongar, we recommend that Kermit Gosnell be charged with two counts of criminal solicitation.

• Hindering prosecution, obstruction of justice, tampering with evidence, and perjury in relation to the death of Karnamaya Mongar

Gosnell and some of his staff attempted to cover up their criminal activity and mislead investigators. On November 19, 2009, when emergency personnel arrived at the clinic long after Karnamaya Mongar had stopped breathing, Sherry West snatched the victim’s file. On the way to the hospital, she evidently made misleading notations, indicating that Mrs. Mongar had received minimal Demerol – only two “local” (10-mg.) doses.

She did so despite being fully aware that, having received Gosnell’s instructions over the telephone a few hours before, Williams had actually given Mrs. Mongar far more Demerol. West thus withheld from emergency personnel trying to save Mrs. Mongar’s life the crucial fact that the victim had received massive amounts of Demerol.

Emergency room records reflect that someone from the clinic – and West was the only person from Gosnell’s clinic to go to the emergency room – provided false information about the circumstances preceding Mrs. Mongar’s cardiac arrest. The records state “that the patient had an uneventful vacuum abortion and was in the recovery room watching TV when she suddenly became unresponsive.” As Dana Kuzma, one of the EMTs who treated Mrs. Mongar testified, “that is just a complete lie.” Ashley Baldwin agreed, “That is a lie.” Mrs. Mongar’s family members testified that they had not provided this information – not only did they not speak English, but they had no idea what happened at the clinic.

After Mrs. Mongar was rushed to the hospital, West told coworkers, including Ashley Baldwin, that Mrs. Mongar “took some pills, because she was trying to get rid of it at home.” This, too, was pure invention. Liz Hampton testified that the Mongar family had told her this, in English, which she claimed they spoke “very well.” But the Grand Jurors heard the testimony of the family members through an interpreter, and thus know this to be untrue.

The toxicology expert confirmed there was no evidence that Mrs. Mongar had taken any abortifacient or other medication. Moreover, West’s and Hampton’s attempt to misdirect blame at the victim was discredited by the expert testimony establishing that it was the overdose of Demerol, not some mystery pill, that killed Mrs. Mongar. West later lied to homicide detectives by telling them that Williams had given Mrs. Mongar only a “local,” (10-mg Demerol) dose. West subsequently told the FBI that Williams had given her a “local” (10 mg.) and then a “custom” (75 mg.) dose of medication. The toxicology analysis established that this account also was false. Gosnell tried to mislead investigators as well. FBI Agent Huff, DEA Investigator Stephen Dougherty, and District Attorney’s Detective James Wood interviewed Gosnell at the clinic on February 18, 2010. Gosnell claimed to have been at the clinic when Demerol was given to Mrs. Mongar. Agent Huff then spoke to Williams, who confirmed that Gosnell was not at the clinic at any time when drugs were given to Mrs. Mongar. Agent Huff returned to Gosnell who told him, again, that any medication given to Mrs. Mongar was administered was while he was at the clinic.

Gosnell stated that he had given one dose to Mrs. Mongar and that a “nurse” may have medicated her at his direction and while he was present at the clinic. Gosnell’s fabricated account not only was self-serving, in that he claimed to have been supervising his employees, but it also served to hinder apprehension of Williams and West for their involvement in Mrs. Mongar’s death. We recommend that Kermit Gosnell be charged with the crime of hindering.

Because West also actively sought to minimize Williams’s and Gosnell’s culpability for Mrs. Mongar’s death by providing false or misleading information, we recommend that Sherry West be charged with tampering with or fabricating physical evidence, tampering with records, and hindering apprehension or prosecution. We recommend charging Liz Hampton with perjury in light of her patently false testimony to the Grand Jury about events surrounding the death of Mrs. Mongar.

• Illegal late-term abortions

Pennsylvania law generally prohibits abortions when a woman is 24 or more weeks pregnant. We recommend that Kermit Gosnell be charged with 33 counts of performing illegal abortions. From the testimony and the evidence we have reviewed, we believe that Gosnell performed scores more such abortions. Violation of this law, however, is subject to a two-year statute of limitations. And investigators to date have been able to locate only a portion of Gosnell’s files from the past two years. Gosnell’s staff consistently told us that he regularly performed abortions after the 24-week limit. Latosha Lewis saw patients who were as much as 26 weeks pregnant “very often.” Kareema Cross testified, “our clinic was the clinic that it doesn’t matter how many weeks you are, he’ll do it.” Steve Massof estimated that 40 percent of supposed second-trimester abortions were actually greater than 24 weeks. Gosnell’s employees told us that when an ultrasound indicated that a woman was more than 24 weeks pregnant, Gosnell would conduct another ultrasound, manipulating the transducer to distort the image and produce a false reading of an earlier pregnancy.

Williams explained to the FBI that Gosnell “dummies” the paperwork. Cross told us, “If it’s a big baby, he [Gosnell] never tell us the truth.” She testified that when Gosnell manipulated ultrasounds to disguise late abortions, “He’ll always say the baby was 24.5." Latosha Lewis told us the same thing.

This testimony was corroborated by numerous patient files showing woman after woman to be precisely 24.5 weeks pregnant before Gosnell performed an abortion. In many of these files there were multiple ultrasounds, including those showing that the woman was more than 24 weeks pregnant.

Ironically, in falsifying gestational ages, Gosnell routinely designated late-term pregnancies as 24.5-week pregnancies, yet 24.5 weeks is too late. Pennsylvania law prohibits abortions “when the gestational age of the unborn child is 24 or more weeks,” 18 Pa.C.S. § 3211(a); the legal limit is thus 23 weeks and 6 days. Even accepting at face value the remarkable coincidence of so many supposed 24.5-week pregnancies, every single one of those terminations was an illegal abortion.

In the presentment, we have listed 31 instances where, based on our examination of patients’ files, we found that Gosnell performed illegal late-term abortions; we recommend felony charges for each of these instances. In addition, we recommend that Gosnell be charged with two counts of performing illegal abortions on 28-week-old Baby Boy B and 26-week-old Baby Girl A, discussed in an earlier section.

We recommend that Lynda Williams and Sherry West be charged with performing illegal late-term abortions, and that Kermit Gosnell, Williams, and West be charged with conspiracy to perform abortions beyond 24 weeks. We have specific evidence that Williams assisted Gosnell in 13 of the 31 illegal abortions listed in the presentment, and that West assisted Gosnell with one of these cases.

We recommend prosecuting Pearl Gosnell for performing, and conspiring with her husband to perform, illegal abortions, based on testimony that she assisted him on Sundays. That was the day, according to the other staff, that very late-term abortions were done. Pearl testified that she alone assisted on Sundays, and that her role was to “help do the instruments” in the procedure room and to monitor patients in the recovery room. Lewis testified that Pearl assisted with late-term abortions “on Sundays or days we were closed [to] do special cases.”

We heard testimony about one Sunday patient, a 14-year-old girl who was almost 30 weeks pregnant, far beyond the 24-week limit. She said she was scheduled to undergo the abortion procedure on Sunday, July 13, 2008. At home at 3:00 a.m. Sunday, however, her membranes ruptured after several hours of labor and she went instead to Crozer Chester Hospital. There, she delivered a stillborn baby girl. The medical examiner of Delaware County determined that the baby girl was at least 29 weeks old, and possibly as old as 34 weeks.

• Violations of the Abortion Control Act

Under Pennsylvania’s Abortion Control Act, a doctor must counsel a patient and obtain her written consent at least 24 hours before performing an abortion. The physician must inform the patient at least 24 hours before an abortion of:

    • (i) The nature of the proposed procedure or treatment and of those risks and alternatives to the procedure or treatment that a reasonable patient would consider material to the decision of whether or not to undergo the abortion.
    • (ii) The probable gestational age of the unborn child at the time the abortion is to be performed.
    • (iii) The medical risks associated with carrying her child to term.

In addition, at least 24 hours before an abortion, the physician or an assistant must provide the patient with certain state-mandated information. The patient must certify, in writing, that she has received the required information.

Gosnell did not bother with these requirements. He did not counsel patients as required by law – he usually did not meet or even speak to them before completing their abortions. Mrs. Mongar’s sole contact with Gosnell, for example, was while she lay unconscious on the procedure table. According to Kareema Cross, in the four years she worked at the clinic, “we never did it,” referring to the state-required counseling. Instead patients were given a piece of paper to sign. That was it for “informed consent.”

Gosnell ignored the 24-hour waiting period, and instead offered some patients same-day procedures. Latosha Lewis told us:

    • They would be able to come in 10 [a.m.] to 4 [p.m.], do an ultrasound and blood work . . . [and] we would ask them, did you want to stay today, have your procedure done, even though by state law, we were supposed to give them 24 hours.

FBI agent Catherine Carter testified that Lynda Williams explained that, at an abortion patient’s initial visit, a staff member has her sign the consent form. We found 243 instances in which the patient then had an abortion on the same day that she signed the consent form. We also found files where there was no consent form, the consent form was not signed, or the consent form was not dated. All of these constitute violations of the law. We recommend that Kermit Gosnell be charged with 310 counts of violating the Abortion Control Act.

• Abuse of corpse

We heard evidence that Gosnell often mutilated dead babies and fetuses by cutting off their feet, which he, weirdly, kept in specimen jars in the clinic. During the February 2010 raid, investigators were shocked to see a row of jars on a shelf in the clinic containing fetal parts. Kareema Cross showed us several photographs that she took in 2008 of a closet where Gosnell stored jars containing severed feet of fetuses. Ashley Baldwin testified that she saw about 30 such jars.

None of the medical or abortion experts who testified before the Grand Jury had ever heard of such a disturbing practice, nor could they come up with an explanation for it. The medical expert on abortions testified that cutting off the feet “is bizarre and off the wall.” The experts uniformly rejected out of hand Gosnell’s supposed explanation that he was preserving the feet for DNA purposes should paternity ever become an issue. A small tissue sample would suffice to collect DNA. None of the staff knew of any instance in which feet were ever used for this purpose.

It is a crime for a person to treat “a corpse in a way that he knows would outrage ordinary family sensibilities.” We were as outraged as the medical experts at this practice.

The following severed feet and a fetus without feet were discovered in the 2010 raid:

    • • The feet of a 22-week fetus in specimen containers that the medical examiner referred to as 4C-1 and 4C-2. These containers were labeled with the same name and the date 12/5/09. Each foot was in a separate container. The medical examiner found with respect to each foot that “the distal portion of the leg has been sharply transected 2.5 cm above the sole of the foot.”

    • • A 21-week fetus, gender indeterminate, found in a plastic bleach bottle, wrapped in red biohazard bag 3F. The medical examiner discovered that “Both feet have been severed at the level of the distal leg and are not present in the container.”

    • • The left foot of a 19-week fetus in specimen container 4B. According to the medical examiner, “The distal portion of the leg has been sharply transected 2.7 cm. above the sole of the foot.”

    • • The feet of a 19-week fetus in specimen containers 5B-1 and 5B-2. As to the left foot, the medical examiner found, “The distal portion of the leg has been sharply transected 2.5 cm. above the sole of the foot in an oblique fashion.” As to the right foot, “the distal portion of the leg has been sharply transected 1.9 cm. above the sole of the foot in an oblique fashion.”

We also heard evidence that, after cutting the spinal cords of live babies, Gosnell would put the babies in cut-off milk jugs, water containers, and juice cartons. The intact body of one 28-week-old male, which we previously referred to as Baby Boy B, was discovered in a bag in the clinic’s freezer during the February 2010 raid. It was in a plastic water container with the top cut off, along with the placenta and gauze pads. The baby had a surgical incision at the base of the neck and was determined by the medical examiner to have been viable.

The Medical Examiner testified:

    • But certainly things like drink containers, milk containers, water containers, this is not something we do in medical practice. . . . What I do does not deal with living patients, and I would not put something in a plastic drink container. It just – it feels wrong I guess is what I’m saying. It feels wrong.

Based the evidence, we recommend that Gosnell be charged with five counts of abuse of corpse.

• Theft by deception

Gosnell hired unqualified staff because he could pay them low wages, often in cash, “under the table.” These staff members included two medical school graduates, Steven Massof and Eileen O’Neill, who testified that they never had valid Pennsylvania medical licenses while working for Gosnell.

According to the testimony of other workers, “Dr. O’Neill” and “Dr. Steve” held themselves out to be doctors. Gosnell hired them knowing that they were not licensed to provide medical care and, as Massof and O’Neill testified, paid them a pittance to treat patients in his absence. Kareema Cross told us that both acted and practiced like doctors, and that she and other workers believed them to be doctors.

Patients were duped as well. Massof testified that he wrote prescriptions for patients on pads pre-signed by Gosnell. Della Mann, a registered nurse and former clinic employee, was a long-time patient of O’Neill’s who said she was shocked to discover recently she was not a licensed physician.

We reviewed Della Mann’s file. It contains 14 faxes sent by Ms. Mann addressed to “Dr. Gosnell, Dr. O’Neill” and 3 addressed solely to “Dr. O’Neill.” A fax dated June 18, 2007 reads: “Dear Dr. Please call Rite-Aid Coreg problem Metforman needed Rite-Aid 215-438-5167.” There is a handwritten note, “Done” on this fax, signed “E” and dated 6/18/07. A fax addressed only to Dr. O’Neill and sent on 2/17/08 with the subject line “Carvedilol 6.25mg bid,” reads: “out of medication please call in Rite aid 215-438-5167.” This fax also contains a handwritten notation, “done – need BP ??,” followed by a signature “E” and the date, 2/18/08.

We found forms in Ms. Mann’s file showing that on 1/30/07, 3/8/07, 6/4/07, and 6/7/07, Dr. O’Neill signed as the clinician for office visits. On each date she observed and treated symptoms and made diagnoses. We also found prescriptions that were written for Ms. Mann on 3/8/07, 6/7/07, 8/10/07, and 12/1/07; these appear to be in the same handwriting as on the patient visit information and the handwritten notes on the faxes signed “E.” Two of these prescriptions are for “Coreg” and one is for “metformin.” Our examination of Ms. Mann’s file shows that two $80 claims were submitted to Independence Blue Cross for Ms. Mann’s March and June 2007 visits.

Della Mann was not the only patient who was deceived. We found 10 other examples of patients who paid Gosnell’s clinic for examination and treatment by a doctor, but were instead treated by “Dr. O’Neill” or “Dr. Steve.” We recommend that Kermit Gosnell, Eileen O’Neill, and Steven Massof be charged with theft by deception and conspiracy to commit theft by deception. Based on patient dates within the past five years in the cases listed above, and the testimony and evidence provided by Della Mann, summarized above, we recommend nine counts of theft against O’Neill, one count against Massof, and 10 against Gosnell.

• Perjury in relation to the unauthorized practice of medicine

Eileen O’Neill testified before the Grand Jury under oath that she did not treat patients at Gosnell’s clinic. She testified that she would “see” patients if Gosnell asked and when he was present, but “I never decide what treatment is.” She claimed she did not see patients alone, that Gosnell would at least “st[i]ck his head in,” and that everyone knew she was not a licensed doctor.

But Della Mann testified that she had no idea that her long-time “doctor,” O’Neill, was not a licensed doctor. Employees testified that they believed she was a legitimate doctor. And the patient files we reviewed showed that, contrary to her sworn testimony, O’Neill examined and treated patients. She performed medical abortions. She wrote out prescriptions.

O’Neill also testified that she did not work on Wednesdays. But our review of patient files shows that she did see patients on Wednesdays. The Wednesday patient visits are significant because Gosnell was not present at the clinic to treat patients on Wednesdays; O’Neill thus would have treated these patients without supervision, notwithstanding her testimony that Gosnell was always present when she saw patients.

Randy Hutchins testified that on Wednesdays, O’Neill was at the clinic by herself. He also told us that other days she came in “an hour or two before [Gosnell] did” and upon her arrival there were “patients waiting to see her.”

Based on this evidence we recommend charging Eileen O’Neill with false swearing and perjury.

• Violations of the Controlled Substances Act in relation to the illegal administering and prescription of drugs

Steven Massof testified that when Dr. Gosnell was not present, he would administer drugs to patients. Kareema Cross confirmed that “in the procedure room he [Massof] did the IV’s, he did patient medications.” Massof also testified that Gosnell left him pre-signed prescription pads, allowing him to prescribe medicine for patients, even though he was not authorized to write prescriptions.

Based on this evidence we recommend that Kermit Gosnell and Steven Massof be charged with conspiring to violate the Controlled Substances Act.

• Corrupt organization

We recommend charging Kermit Gosnell, Lynda Williams, Sherry West, Eileen O’Neill, Steven Massof, and Tina Baldwin with violating the corrupt organization statute, 18 Pa.C.S. § 911, based on a pattern of racketeering activity. We recommend that these same six individuals as well as Pearl Gosnell and Maddline Joe be charged with conspiring to commit racketeering activity.

“Racketeering activity” includes violations of chapter 25 of the Crimes Code (homicide), chapter 39 (theft), section 13 of the Controlled Substances Act, and conspiracy to commit any of these violations. A “pattern of racketeering activity” means “two or more acts of racketeering activity.” It is “unlawful for any person employed by or associated with any enterprise to conduct or participate, directly or indirectly, in the conduct of such enterprise’s affairs through a pattern of racketeering activity.” 18 Pa.C.S. § 911(b)(3).

Gosnell ran a corrupt organization. He performed illegal late-term abortions that resulted in babies born alive, whom he killed, or had others kill; he directed his workers to sedate patients with narcotics in violation of the controlled substances act; and he employed bogus doctors to treat unsuspecting, paying patients. Maddline Joe, his office administrator, collected the money that came in from these criminal activities. Williams, West, O’Neill, Massof, Tina Baldwin, and Pearl Gosnell all actively participated in various aspects of Gosnell’s corrupt organization.

The Grand Jury received evidence of multiple violations of Chapter 25. These included not only the specific murders discussed earlier in this report, but also the ongoing pattern of killing babies born alive by Gosnell, Massof, Williams, and Moton. Patient files show that Tina Baldwin assisted with these late abortions. So did Pearl Gosnell. By aiding very late-term abortions, they conspired with Kermit Gosnell to kill living babies delivered by their unconscious mothers.

We heard ample evidence, summarized earlier in this report, regarding recurrent violations of the Controlled Substances Act. Steven Massof, Lynda Williams, Sherry West, Tina Baldwin, and Adrienne Moton, as part of their duties for which Gosnell hired them, conspired with him to violate the drug laws by agreeing to illegally administer narcotics to patients.

Gosnell’s corrupt enterprise also involved theft. Gosnell employed bogus doctors, deceiving patients who thought they were being treated by, and paying for treatment by, bona fide physicians. O’Neill and Massof each conspired with Gosnell to commit thefts by deception, as we explained above. These thefts were integral to Gosnell’s corrupt enterprise. As numerous witnesses testified, he largely ran his practice in absentia and hired the fake doctors to treat patients in his absence.

Maddline Joe worked for Gosnell for more than 20 years, most recently as the office administrator. She testified that in that role she ordered and paid for Demerol. As many employees testified, it was a long-standing, established practice at Gosnell’s clinic that this drug was to be given to patients by unlicensed workers and without medical supervision. Joe also testified that she paid Gosnell’s workers and that she handled the money paid to the clinic by patients. She said she also saw patient files. We did too, and we saw that non-doctors Massof and O’Neill treated and examined many patients.

Gosnell, with the assistance of Maddline Joe, received the fees collected from duped patients.

We have concluded there is probable cause to believe that each of these persons knowingly agreed with Gosnell to participate in his corrupt organization. We recommend that charges of conspiracy to violate the corrupt organizations statute be brought against Kermit Gosnell, Pearl Gosnell, Lynda Williams, Sherry West, Adrienne Moton, Steven Massof, Eileen O’Neill, Tina Baldwin, and Maddline Joe.

• Obstruction of justice and tampering with evidence in relation to the destruction of files

Between the time that law enforcement officials raided Gosnell’s office in February 2010 and the time that investigators returned with a warrant to seize patient files, many files disappeared. We viewed a videotape of the raid and saw files on shelves outside the procedure rooms. Latosha Lewis and others told us that these were recent second-trimester abortion files. The shelves were bare when investigators returned.

Tina Baldwin testified that “second trimester charts, usually those real big ones, they didn’t stay in the office.” Other employees corroborated her observation. Gosnell took those files home, Baldwin said, “if there were difficult cases or some cases where he thought they shouldn’t be in there.” A subsequent search of Gosnell’s home and car turned up only some of these files. Massof told us that Gosnell always took files home, so “I think he has them. If he hasn’t destroyed them, he has them.”

We also learned from the state Department of Health that sometime after the February 2010 raid, Gosnell suddenly filed numerous reports of abortions, including previously unreported second-trimester abortions. To complete the detailed health department forms, Gosnell would have had to have the patient files. We have reviewed these forms and, for the most part, the corresponding patients files are missing. In a letter accompanying his March 2010 submission to the Department of Health, Gosnell advised that the information came “from patient charts [that] have been removed from the facility.”

Based on this evidence, we believe that Gosnell, aware he was under investigation, intentionally destroyed or disposed of patient files. This constitutes intentional obstruction of “the administration of law or other governmental function by . . . physical interference or obstacle.” 18 Pa.C.S. § 5101 (obstruction). It also constitutes tampering with physical evidence. 18 Pa.C.S. § 4910 (tampering). We recommend that Kermit Gosnell be charged with obstruction and tampering.

• Corruption of the morals of a minor

Gosnell hired high school student Ashley Baldwin to medicate patients, in violation of the Controlled Substances Act, and to assist with illegal abortions, in violation of the Abortion Control Act. Ashley’s mother had worked at the clinic for years, assisting Gosnell with abortions, including illegal late-term abortions, and with medicating patients, in violation of the Controlled Substances Act.

Ashley was only 15 when she began working for Gosnell. He subsequently trained her, as he had trained her mother, to assist with abortions and give medications to patients. Tina Baldwin and Ashley Baldwin both testified that Gosnell would keep Ashley at the clinic, assisting with abortions, sometimes until well after midnight, even though Ashley was still in high school. Tina Baldwin knew her daughter was being directed to perform tasks that she was not authorized to do.

We recommend charging Kermit Gosnell with corruption of a minor. We also recommend that Tina Baldwin be charged with the same crime. Tina worked for Gosnell for several years before recommending her daughter for employment. As Ashley’s involvement in Gosnell’s illegal practices became deeper – at one point she was working 50-hour weeks and well past midnight, while trying to complete high school – Tina did nothing to curtail her minor daughter’s exploitation by Gosnell.

We also reviewed evidence that Gosnell did not obtain parental consent, as required under the Abortion Control Act, before performing abortions on minors. The law bars such patients from obtaining abortions without parental consent or judicial approval, but Gosnell went ahead and performed the abortions. Based on two files from the past two years, in which we found there was no parental signature, we recommend two additional charges against Kermit Gosnell for corruption of a minor.