Women’s+Medical+Society

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.

=**The Women’s Medical Society was filthy **= toc  The Grand Jury toured the facility at 3801 Lancaster Avenue. It is unbelievable to us that the Pennsylvania Department of Health approved this building as an abortion facility. We were stunned to learn that, between 1978 and 1993, the department sporadically inspected and approved the clinic, and then never inspected it again until February 2010, when health department employees entered the facility at the request of law enforcement officials who were investigating allegations of the illegal sale of drugs and prescriptions.
 *  and totally unsuitable as a medical office or a surgical facility. **

 The physical layout of the clinic, a confusing maze of narrow hallways and multiple twisting stairways, should have been an obvious bar to its use for surgical procedures. The three-story structure, created by joining two buildings, had no elevator. Access from procedure rooms to the outside by wheelchair or stretcher was impossible, as was evident the night Karnamaya Mongar died.

 According to former staff members, the facility had been substantially cleaned up by the time the Grand Jury visited it. Between late February 2010, when the practice was closed, and our tour of the clinic in August, significant efforts had been made to make the facility look and smell cleaner. Despite such efforts, it remained a wretched, filthy space.

 The walls appeared to be urine-splattered. The procedure tables were old and one had a ripped plastic cover. Suction tubing, which was used for abortion procedures – and doubled as the only available suction source for resuscitation – was corroded. A large, dirty fish tank stood in the waiting room, filled with turtles and fish. The dirt-floored basement was stuffed with patient files, plants, junk, and boxes of un-disposed-of medical waste. The entire facility smelled foul. These were the conditions after the facility had been shut down and cleaned.

 Former employees, including Latosha Lewis and Kareema Cross, testified to the abhorrent conditions when the clinic was operating. They described the odor that struck one immediately upon entering – a mix of smells emanating from the cloudy fish tank where the turtles were fed crushed clams and baby formula; and from boxes of medical waste that sat around for weeks at a time, leaking blood, whenever Gosnell failed to pay the bill to the disposal company.

 They described blood-splattered floors, and blood-stained chairs in which patients waited for and then recovered from abortions. Even the stirrups on the procedure table were often caked with dried blood that was not cleaned off between procedures. There were cat feces and hair throughout the facility, including in the two procedure rooms. Gosnell, they said, kept two cats at the facility (until one died) and let them roam freely. The cats not only defecated everywhere, they were infested with fleas. They slept on beds in the facility when patients were not using them.

Kareema Cross testified about the procedure rooms: “The rooms were dirty. Blood everywhere. Dust everywhere. Nothing was clean.” The bathrooms, according to Lewis, were cleaned just once a week despite the fact that patients were vomiting in the sinks and delivering babies in the toilets.



 Medical waste and fetal remains were supposed to be picked up weekly by a licensed disposal provider. Gosnell, however, did not pay his bills in a timely manner, and the disposal provider would not pick up – sometimes for months. In the interim, and as the search team discovered during the February 18 raid, freezers at the clinic were full of discarded fetuses, and medical waste was piled up in the basement.



 Sometimes, according to Tina Baldwin, fetal remains were left out overnight. “You knew about it the next day when you opened the door … Because you could smell it as soon as you opened the door.” According to a plan that Gosnell filed with the Philadelphia Health Department in 2004, waste was to be stored in the basement for once-a-week pickup by a waste disposal company. But he didn’t follow the plan. He failed to pay his bills. Weeks went by without a pickup, and the containers in the basement leaked.



**Gosnell used and reused unsanitary instruments to perform abortions. **
The instruments that were inserted into women’s bodies were also unsanitary, according to the workers. Kareema Cross showed the Grand Jury a photograph she had taken, showing how the instruments were purportedly sterilized. The photo shows a pan on the floor. In it are the doctor’s tools, supposedly soaking in a sterilizing solution. But the photo shows that the instruments cannot get clean because they do not fit in the pan, and are not submerged. Gosnell would nonetheless pluck instruments from this pan on the floor and use them for procedures. Cross said that she saw Gosnell insert into a woman’s vagina a speculum that was still bloody from a previous patient. She testified about how Gosnell would ignore her complaints about his unsanitary practices:

>> The instruments were dirty. It was plenty of times that I had complained. He’ll – it would be a spec, a speculum and he’ll use it. I would complain – I’ll leave the speculum on his tray, so he can see it. So he can say something to whoever is cleaning them. It’ll have blood on it. And he would still use it and it was a lot of girls that was complaining about getting infections. . . trichonomas, chlamydia because of the instruments not being cleaned.

 Several workers testified that Gosnell insisted on reusing plastic curettes, the tool used to remove tissue from the uteruses, even though these were made for single use only. Latosha Lewis testified that Gosnell would make his staff reuse the curettes until they broke. Like Cross, Lewis believed it was the unsanitary instruments that were causing patients to become infected with chlamydia and gonorrhea.

<span style="font-family: 'Courier New',Courier,monospace;"> When inspectors from Pennsylvania’s Departments of Health and State surveyed the facility in February 2010, they corroborated much of what the former staff members described. Department of Health workers found that the suction source used by the doctor to perform abortions was the only one available to resuscitate patients. They found the tubing attached to the suction source was “corroded.” They also described the suction source’s vacuum meter as “covered with a brown substance making the numbers on the meter barely readable.” An oxygen mask and its tubing were “covered in a thick gray layer of a substance that appeared to be dust.”



<span style="font-family: 'Courier New',Courier,monospace;"> The inspector from the Department of State reported: “The clinic conditions are deplorable and unsanitary … There was blood on the floor and parts of aborted fetuses were displayed in jars.”

**<span style="font-family: 'Courier New',Courier,monospace;">Gosnell had unlicensed and unsupervised staff **

 * <span style="font-family: 'Courier New',Courier,monospace;"> routinely administer potent and dangerous drugs when he was not present at the clinic. **

<span style="font-family: 'Courier New',Courier,monospace;"> As bad as the physical condition of the facility was, the practice that Gosnell conducted inside of it was even worse. It was not a mistake or an exceptional circumstance that forced Lynda Williams and Sherry West to sedate Mrs. Mongar when Gosnell was absent from his clinic. According to multiple staff members, that was routine procedure. In fact, Gosnell, the clinic’s only licensed medical provider, rarely arrived at all before 8:00 p.m. Abortion patients, on the other hand, began arriving as early as noon.

<span style="font-family: 'Courier New',Courier,monospace;"> It was Gosnell’s intention and instruction that his untrained and unlicensed staff administer drugs – both to initiate labor and to sedate patients – before he arrived. Patients, meanwhile, did not receive individual medical consideration. Drugs were administered without regard to a patient’s weight, medical condition, potential risk factors, or any other relevant factors that physicians need to weigh in determining appropriate medication. Gosnell ordered his untrained and inexperienced staff to administer drugs to patients even when they protested, as 16-year-old Ashley Baldwin did, that they were not qualified. Gosnell told Ashley and other employees that if they were not willing to administer medication and anesthetize patients, procedures that Pennsylvania law requires a medical license to perform, they could not work at the clinic.

<span style="font-family: 'Courier New',Courier,monospace;"> As Kareema Cross explained it, Gosnell told her when she was first hired that it was her job to medicate the patients when they were in pain. But after assigning this as one of her job responsibilities, he did not oversee what she did on individual patients. Indeed, he couldn’t oversee his workers as they anesthetized patients, because he was usually not at the clinic when they did so. His practice was to leave it to the untrained workers to decide when to medicate and re-medicate the patients. He also left the precise medication mixture to the judgment of his unlicensed, untrained staff.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell disliked it when workers disturbed him by calling for medication advice. Ashley told us that he complained that they were “rushing him.” According to Lewis, “You had to rely on your own. If you felt like they were in pain and you wanted to administer medication, you would just administer the medication yourself.”

<span style="font-family: 'Courier New',Courier,monospace;">Williams was known by other staff members to improvise her own drug cocktails. She would give a patient “[w]hat she thought she needed,” according to Ashley. “She used what she wanted.” West would do the same. Other staff members repeatedly reported this dangerous practice to Gosnell, yet he continued to give Williams responsibility for drugging his second-trimester patients. Cross warned Gosnell in 2008 that Williams gave too much medication, but “Gosnell didn’t care what she did.” Cross would tell Williams that she was giving too much medication; Williams would respond, “well, that is what Dr. Gosnell told me to give.”

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s practice of having unqualified personnel administer anesthesia began years before the death of Mrs. Mongar. We heard from a former employee, Marcella Stanley Choung, who told us that her “training” for anesthesia consisted of a 15-minute description by Gosnell and reading a chart he had posted in a cabinet. She was so uncomfortable medicating patients, she said, that she “didn’t sleep at night.” She knew that if she made even a small error, “I can kill this lady, and I’m not jail material.” One night in 2002, when she found herself alone with 15 patients, she refused Gosnell’s directives to medicate them. She made an excuse, went to her car, and drove away, never to return.

<span style="font-family: 'Courier New',Courier,monospace;"> Choung immediately filed a complaint with the Department of State, but the department never acted on it. She later told Sherilyn Gillespie, a Department of State investigator who participated in the February raid, that she has worked at seven different abortion clinics and “she has never experienced an illegally run, unsanitary, and unethical facility such as the Women’s Medical Society operated by Dr. Gosnell.” She has never reported any other provider or facility to state authorities.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell knew that using unlicensed and uncertified staff was wrong. He had testified in the criminal trial of a man charged with illegally practicing medicine by assisting Gosnell with abortion procedures in 1972. In 1996, he was censured and fined in two states – Pennsylvania and [|New York] – for employing unlicensed personnel in violation of laws regulating the practice of medicine. As far back as 1989, and again in 1993, the Pennsylvania Department of Health cited him for not having any nurses in the recovery room. Gosnell ignored the warnings and the law. He just paid his fines and knowingly continued the dangerous practice of employing unqualified personnel to administer dangerous drugs. It was his modus operandi.

**<span style="font-family: 'Courier New',Courier,monospace;"> Patients were allowed to choose any level of sedation, **

 * <span style="font-family: 'Courier New',Courier,monospace;">as long as they paid for it. **

<span style="font-family: 'Courier New',Courier,monospace;">Gosnell did not actually prescribe the amount of medicine, if any, to be used on a particular patient. Instead, he had his staff offer patients a list of medications that could be bought a la carte, in differing quantities, for first-trimester abortions. This practice demonstrates that he was not really practicing medicine; he was running a money-making racket, cutting corners and endangering patients to maximize his profits.

<span style="font-family: 'Courier New',Courier,monospace;"> Second-trimester patients always received the highest level of sedation – usually after being administered multiple lesser doses – as part of their package price. The age, size, health, and other characteristics of the individual patient were immaterial to the dosage. Often clinic staff would begin administering medicine chosen by the patient <span style="font-family: 'Courier New',Courier,monospace;"> before the doctor ever saw the patient. It was routine for the unlicensed workers to heavily sedate second-trimester patients hours before the doctor arrived at the clinic. Even when Gosnell was in the clinic, he did not give written or oral orders for medication. Rather, the unlicensed workers determined the mix of drugs they would administer by referring to, although not always following, a chart that was posted in the recovery room. The chart – a “cheat sheet” of the clinic’s sedation cocktails – was handwritten by high-school-student Ashley Baldwin, who worked every night except Sunday at the clinic, performing a variety of medical procedures for which she had no training.

<span style="font-family: 'Courier New',Courier,monospace;"> Ashley’s color-coded chart described the various levels of sedation that Gosnell provided, and the mix of drugs that comprised them, as follows:

>> <span style="font-family: 'Courier New',Courier,monospace;"> (1) Local (10 mg. of nalbuphine and 12.5 mg. of promethazine); >> <span style="font-family: 'Courier New',Courier,monospace;"> (2) Heavy (50 mg. Demerol, 12.5 mg. promethazine, and 5mg. diazepam); >> <span style="font-family: 'Courier New',Courier,monospace;"> (3) Twilight (75 mg. Demerol, 12.5 mg. promethazine, and 7.5 mg. diazepam); and >> <span style="font-family: 'Courier New',Courier,monospace;"> (4) Custom (75 mg. Demerol, 12.5 mg. promethazine, and 10 mg. diazepam).



<span style="font-family: 'Courier New',Courier,monospace;">Latosha Lewis described how she and the other unlicensed staff members presented the choice of medication to the clinic’s patients:

>> <span style="font-family: 'Courier New',Courier,monospace;"> You can pick which anesthesia you want to receive, whether you want to be up, half asleep, if you want to be knocked out, and it’s additional to your procedure, but local anesthesia is included in the smaller cases and custom anesthesia, which is the highest, to be put to sleep in the bigger cases.

<span style="font-family: 'Courier New',Courier,monospace;"> An “Anesthesia for Surgery” form Appendix B] presented to patients for their signature – and payment – did not identify or describe the drugs to be administered. However, it suggested:

>> <span style="font-family: 'Courier New',Courier,monospace;"> It will probably be best to pay the extra money and be more comfortable if some of the following conditions are true for you. >>> <span style="font-family: 'Courier New',Courier,monospace;"> 1. The decision to have the procedure is a difficult decision. >>> <span style="font-family: 'Courier New',Courier,monospace;"> 2. Medication is usually necessary for your menstrual cramps. >>> <span style="font-family: 'Courier New',Courier,monospace;"> 3. Your decision has been forced by your parents or partner. >>> <span style="font-family: 'Courier New',Courier,monospace;"> 4. Your family members or friends “don’t like pain.”

<span style="font-family: 'Courier New',Courier,monospace;"> The “Custom” mix of medications is described on the form as follows:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Most women who choose CUSTOM SLEEP want to feel ABSOLUTELY NO CRAMPS OR PAIN during their procedure. A needle with an anticlotting medication is inserted prior to the procedure and sedation is repeatedly administered until the patient is comfortable throughout the procedure.

<span style="font-family: 'Courier New',Courier,monospace;"> The form has a place to sign next to “I choose CUSTOM SLEEP” and a blank where the price of the “Custom” option is handwritten in. The price of the “Custom” sedation is $150. The form explains the effects of the “Twilight Sleep” concoction in this way:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Most women who choose TWILIGHT SLEEP want to feel VERY FEW OR VERY SLIGHT CRAMPS during their procedure.

<span style="font-family: 'Courier New',Courier,monospace;"> The cost listed is $90, which was in addition to the cost of the procedure. The form describes the clinic’s “Heavy Sedation” option:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Most women who choose HEAVY SEDATION feel SLIGHT TO MODERATE CRAMPS during their procedure.

<span style="font-family: 'Courier New',Courier,monospace;"> Heavy sedation cost $50 extra.

<span style="font-family: 'Courier New',Courier,monospace;"> All of the drugs listed on the chart, including those that put patients into a deep sleep and could be considered general anesthesia, were offered to patients undergoing first-trimester abortions – a procedure that usually takes only a few minutes and is relatively pain-free even without medication. Legitimate abortion clinics give no medication for these procedures, or small doses of a local anesthetic such as lidocaine to numb the immediate area – an entirely different medication from the clinic’s misnamed “local,” which includes a combination of narcotics given intravenously.

<span style="font-family: 'Courier New',Courier,monospace;"> Even if the strong sedatives offered by Gosnell were being administered by licensed professionals – which they were not – the implications of the clinic’s “Anesthesia for Surgery” form are troubling for several reasons. First, decisions on medication dosages were left totally up to patients, and were almost always made without any consultation with a doctor. Even worse, the patients were encouraged to make these decisions based on factors that have nothing to do with medicine – factors as irrelevant to their health as their friends’ feelings about pain.

<span style="font-family: 'Courier New',Courier,monospace;"> Probably most dangerous of all, Gosnell’s form offered patients a choice among varying levels of pain, without any explanation of the risks presented by the various drugs or the effects of increased dosages of the drugs. No legitimate medical practice allows patients to choose their levels of anesthesia, especially when their choices are uninformed and based solely on a description of cost and how much pain the patients wish to feel.

<span style="font-family: 'Courier New',Courier,monospace;"> We were particularly appalled by the reference in the form to a decision being “forced” on a patient by a partner or parents. A legitimate practitioner would never perform forced abortions. Gosnell would and did. As long as he was paid, the patient’s wishes or circumstances were not his concern.

**<span style="font-family: 'Courier New',Courier,monospace;"> Patients received multiple, heavy doses of sedatives **

 * <span style="font-family: 'Courier New',Courier,monospace;">that kept them anesthetized for several hours with no licensed medical professional on the premises. **

<span style="font-family: 'Courier New',Courier,monospace;"> In addition to revealing the mercenary, rather than medical, nature of Gosnell’s practice, the anesthesia form confirms what Latosha Lewis and Kareema Cross told the Grand Jury: the “custom” medication administered to second-trimester patients was not just a single dose that was administered to keep the patients asleep through a surgical procedure of limited duration. Rather, the medication was first “inserted prior to the procedure” and sedation was “repeatedly administered” until the procedure was completed.

<span style="font-family: 'Courier New',Courier,monospace;"> Cross testified that she and the other workers would administer the “custom” dose of medication just before the doctor performed the procedure. But all day long, the staff had been administering powerful “twilight” levels of the sedating drugs:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And what about if the patient was 20 to 24 weeks? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: 20 to 24 weeks, [Dr. Gosnell] will do dilation for two days. For 23 to 24, he’ll do dilation for two days and. . . he’ll go in. We’ll give them the medication to put them to sleep. At that time we give them custom. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: What’s that? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: More medication. It’s higher than twilight because all day we give them twilight to put them to sleep and make them comfortable. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: So all day you’re putting people to sleep? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And they are waking up sometimes? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And then you’re putting them back to sleep? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How many times would a patient wake up and go back >> <span style="font-family: 'Courier New',Courier,monospace;"> to sleep? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: About three or four times. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Before they’re going in for their procedure? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: So, if a patient is between 20 and 24 weeks, she would >> <span style="font-family: 'Courier New',Courier,monospace;"> get even more additional medication? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: So, she would have already been awake and asleep three >> <span style="font-family: 'Courier New',Courier,monospace;"> or four times throughout the day – >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: because she was given drugs throughout the day? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: By either yourself or Ashley or Sherry or Lynda? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And then when [Dr. Gosnell] arrives on site, on the premises, and he’s getting ready to take care of it, to terminate the pregnancy, he would put the patient to sleep again? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: With a heavier dosage of medication? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Who would give that heavier dosage of medication? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Me, Sherry. Sherry would be in recovery at that time. Me, Lynda, or Ashley. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And would he tell you at that point how much to give or would you just give what you knew to give? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Just give what I knew to give. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How did you know what to give? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Just from looking at the sign. . ..

<span style="font-family: 'Courier New',Courier,monospace;">Cross stated that she would check on patients every hour and give more medication if they were cramping.

<span style="font-family: 'Courier New',Courier,monospace;">Latosha Lewis described the same standard procedures as Cross. She testified that second-trimester patients would arrive at the clinic in the early afternoon. They would be given [|Cytotec] and Restoril by whomever sat at the front desk. Cytotec was given to induce labor by softening the cervix and causing the uterus to contract. Restoril, Lewis explained, was to calm the women’s nerves. Women were then placed in the “recovery room” where any one of the several unlicensed workers placed an IV access in the women’s hands. For the next several hours – sometimes as many as eight or nine – women sat, medicated and in labor until either the doctor, or their baby, arrived. Lewis testified:

>> <span style="font-family: 'Courier New',Courier,monospace;"> We would undress them eventually from waist down, cover them up, and just put a blanket over them and they would sit there for hours while we’re – either every hour on the hour or whenever we got a chance, we’re still giving them more Cytotec. If the IV is in, we’re giving them pain meds through the IVs. And that’s what we’re doing the whole time until the doctor arrives, unless the baby comes out.

<span style="font-family: 'Courier New',Courier,monospace;">Gosnell, she testified, was at home while his patients went into labor and his workers repeatedly medicated them at will. The goal, according to the clinic’s workers, was to keep the patients asleep.

<span style="font-family: 'Courier New',Courier,monospace;"> According to Lewis, the workers would not document what she referred to as the “mini-doses” or “in-betweens” that the workers gave continuously to achieve their goal – a room full of comatose women.

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell used medication – and slaps – **

 * <span style="font-family: 'Courier New',Courier,monospace;">to silence loud or complaining patients. **

<span style="font-family: 'Courier New',Courier,monospace;">Tina Baldwin testified that, while the size and weight of the patients were immaterial to dosages, one factor that did influence the staff’s use of medication was the temperament of the patient. Baldwin said that she would call Gosnell at home when she had a question about medicating a patient:

>> <span style="font-family: 'Courier New',Courier,monospace;"> A:. . . He would ask you what her temperament was, you know. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Why did it matter what her temperament was? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: I don’t know. He would just ask you what it was, you know, what she was doing. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: For instance, if someone was carrying on, really crying out in pain – >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Oh, you would knock them out completely. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Why? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Because he wouldn’t want you – he didn’t want to hear all that. He just didn’t want to hear all that. He didn’t want that in his office. He didn’t like confrontation. He didn’t like nobody calling the police or anything. He didn’t like none of that stuff going on. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: So he would just drug a girl in the back if she was complaining and carrying on? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: If she was out of hand, yeah, she would get put under. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How often would that happen? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Any time somebody got out of hand. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How often would people get out of hand? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Let’s say 24 weeks and you’re feeling all of it, I would say at least three a week, three or four a week, something like that. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And there’s other patients there with her, right? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Yeah. And when it gets like that, we try – they used to take the other patients upstairs through the back way or we would shut the front, shut the door before surgery and that girl that was being a problem, nine times out of ten – you would get her out of the way first. Put her in a room, put her in a room, let’s give her her medication, quiet her up. She’s upsetting everybody else. So usually she would get done first.

<span style="font-family: 'Courier New',Courier,monospace;"> If Gosnell was present in the clinic, drugs might be the back-up plan for subduing unruly patients. Tina Baldwin testified that she saw Gosnell slap a woman on the thigh when she got “a little bit rowdy.” Baldwin explained that when that did not quiet her, he used drugs: “I mean he slapped her and that didn’t work, then he would medicate her and put her under.” According to Baldwin, some women returned to complain and ask why they had slap or hand marks on their thighs.

**<span style="font-family: 'Courier New',Courier,monospace;"> Even when Gosnell was in the building, he did not oversee the administration of anesthesia **

 * <span style="font-family: 'Courier New',Courier,monospace;"> – except when the patient was white. **

<span style="font-family: 'Courier New',Courier,monospace;">Tina Baldwin told the Grand Jury that the untrained medical assistants, without supervision by Gosnell, routinely administered even the final dose of sedation just before the procedure – unless the patient was white. She testified:

>> <span style="font-family: 'Courier New',Courier,monospace;">. . . it was two rooms back there. And if he was working on one person in one room, you were in the other room you were setting that patient up to be done when he’s done because it was just a back and forth thing. You would go ahead and medicate this person before he gets in the room. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Okay. Was he present when you did that medication? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: No, no. And sometimes he asked them – but it was a race thing. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: What do you mean? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: It was – he sometimes he used to – okay. Like if a girl – the black population was – African population was big here. So he didn’t mind you medicating your African American girls, your Indian girl, but if you had a white girl from the suburbs, oh, you better not medicate her. You better wait until he go in and talk to her first. And one day I said something to him and he was like, that’s the way of the world. Huh? And he brushed it off and that was it.

<span style="font-family: 'Courier New',Courier,monospace;"> Tina Baldwin also testified that white patients often did not have to wait in the same dirty rooms as black and Asian clients. Instead, Gosnell would escort them up the back steps to the only clean office – Dr. O’Neill’s – and he would turn on the TV for them. Mrs. Mongar, she said, would have been treated “no different from the rest of the Africans and Asians.”

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell employed a high school student to medicate and monitor abortion patients **

 * <span style="font-family: 'Courier New',Courier,monospace;">until he and other staff arrived at the clinic to perform abortions. **

<span style="font-family: 'Courier New',Courier,monospace;">In September 2006, Gosnell hired Ashley Baldwin, Tina’s daughter, to work at his clinic when she was just 15 years old. She was a sophomore in high school. She came to the clinic each day in the early afternoon. In the beginning, her job was to answer phones and do paperwork. But before the end of her sophomore year, Gosnell assigned her to attend to the abortion patients in the recovery room.

<span style="font-family: 'Courier New',Courier,monospace;"> For about a year, she was working “in the back” with other unlicensed workers who knew Gosnell’s customs and practices. Kareema Cross, Latosha Lewis, Adrienne Moton, and Steve Massof assisted Gosnell with the abortion procedures and were usually at the clinic during the afternoon and evening before the doctor arrived. But as those employees left, or cut back their hours, Ashley became responsible for more and more activities involving patients.

<span style="font-family: 'Courier New',Courier,monospace;"> In addition to attending to the patients in the recovery room, the now high-school junior began to assist Gosnell in the smaller of the two procedure rooms – one the staff referred to as “O’Keefe.” (The larger procedure room, where Gosnell performed laterterm abortions, was named “Monet.”) Gosnell showed Ashley how to operate the ultrasound machine – which he told her was old and didn’t really work – and how to measure and record the size of the fetuses. This became a routine part of her job.

<span style="font-family: 'Courier New',Courier,monospace;"> By her senior year, Ashley was doing just about everything in the clinic except performing surgeries. She testified that Gosnell was coming into the clinic later and later, and that when he came in later, so did Lynda Williams and Sherry West. Often, Ashley was the only person staffing the clinic from the time her mother left at 6:00 p.m. until whenever Williams and West, who drove to work together, arrived. Even when West and Williams were at the clinic, Ashley said, Sherry West preferred to hang around at the front desk instead of working. Ashley testified:

>> <span style="font-family: 'Courier New',Courier,monospace;"> I was just supposed to be in the recovery room, and inside another small room. But since they weren’t there, I had to bring the girls from the front to the back, set them up in both rooms, wait until he got there, if a precipitation happened, I had to handle it on my own.

<span style="font-family: 'Courier New',Courier,monospace;"> By “precipitation,” Ashley meant that women and girls actually delivered babies. They delivered babies when Ashley was the only person present in the clinic to take care of them, their babies, the placenta, and all of the other drugged patients waiting for procedures. By Ashley’s own admission, the women and babies did not get any kind of standard medical care. She described doing the best she could:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Okay. You said that as a senior you would be working and the babies would precipitate and you would be left to take care of it; is that right? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How would you take care of it? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: I would usually tell the girl to go to the bathroom, and I would – there is a phone right by one of the bathrooms, and I would call his phone. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Call whose phone? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Doc. Call his cell phone while he’s running or doing something. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: What do you mean by running? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: He go for a run before he come to work. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And that is why he would get there so late? >> <span style="font-family: 'Courier New',Courier,monospace;"> A:. . . Yes. Or go swimming. And I would wait until he got there, so I would have to sit in the bathroom with the girl. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How many times did you see babies precipitate when you were there? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: A lot. Mostly all the second tri’s mostly.

<span style="font-family: 'Courier New',Courier,monospace;"> Other staff members confirmed that it was standard procedure for women to deliver fetuses – and viable babies – into toilets while patients and staff waited for Gosnell to arrive at the clinic.

<span style="font-family: 'Courier New',Courier,monospace;"> In addition to essentially delivering babies, Ashley medicated patients, performed ultrasounds, filled out patient charts, and diagnosed sexually transmitted diseases using a microscope that she said was not as good as the one in her high school chemistry lab.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell trained Ashley to administer intravenous medication by having her insert an IV “butterfly needle” – once – into his hand and injecting a saline solution. She testified about how he trained her concerning the actual drugs that she would use to medicate patients:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Okay. So there were times when you also gave medication to patients when the doctor wasn’t there? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: What kind of medications did you give? >> <span style="display: block; font-family: 'Courier New',Courier,monospace; text-align: center;">* * * >> <span style="font-family: 'Courier New',Courier,monospace;">A: Doc gave me a chart of medication. I couldn’t really read the chart, so I made the chart over on my own and color coded. And it was diazepam, nalbuphine, sometime Demerol if there was no nalbuphine, and I forgot the other one. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: Promethazine? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Promethazine, Yeah. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: How do you know how much to give a patient? >> <span style="font-family: 'Courier New',Courier,monospace;">A: He gave me a book. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: The doctor gave you a book? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: This is right after you turned 18 as a senior in high school? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: And did you read the book? Did you read the book? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: What did it tell you? >> <span style="font-family: 'Courier New',Courier,monospace;">A: It was a whole lot of percentages and decimal points and stuff. He was just like: you have to focus on this part right here. So, I just read and understood the part that he told me. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: Did you understand the book? >> <span style="font-family: 'Courier New',Courier,monospace;">A: The part that he told me to read, the math, yeah, but not the words. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: Okay. And so how did you know how to mix up or draw up the medications? >> <span style="font-family: 'Courier New',Courier,monospace;">A: He – he did them first, and then he told me to do them in front of him. >> <span style="font-family: 'Courier New',Courier,monospace;">Q: How much training did you get? >> <span style="font-family: 'Courier New',Courier,monospace;">A: Just that twenty minutes.

<span style="font-family: 'Courier New',Courier,monospace;"> Based on this “training,” Ashley would draw up the medications for as many as 20 patients a night. Ashley testified that she also administered drugs to first-trimester patients who would go into the smaller procedure room where she worked. She said that sometimes she would telephone the doctor if one of the first-trimester patients was in pain and he was not at the clinic. He would tell her: “ Well, med them, I’m on my way.” Ashley would then administer the “local ” or, as she referred to the mix, “the blue meds” that were included with the fee for first-trimester patients.

<span style="font-family: 'Courier New',Courier,monospace;"> The Grand Jury noted that, while testifying, Ashley mixed up Demerol with diazepam when describing the drugs that constituted a “heavy” dose. She said the clinic’s “heavy” mix of sedatives contained 50 mg. of diazepam and 12.5 mg. of promethazine. On the chart, however, a “heavy” is described as 50 mg. of Demerol, 12.5 mg. of promethazine, and 5mg. of diazepam. This mistake gave the jurors just a hint of how dangerous Gosnell’s practice – its procedures and its staffing – was for his patients.

<span style="font-family: 'Courier New',Courier,monospace;"> Ashley was working 50 hours a week at the clinic and Gosnell was paying her $8.50 an hour – in cash. On her high school “work roster,” Gosnell wrote that she worked from noon to 6:00 p.m. Her title was “student.” In truth, Ashley often worked until 2:00 a.m. and performed the duties of a registered nurse or a doctor. When asked who was in charge of the clinic before Gosnell arrived, Ashley testified: “Me.”

**<span style="font-family: 'Courier New',Courier,monospace;"> The workers Gosnell hired were incompetent and uncaring **

 * <span style="font-family: 'Courier New',Courier,monospace;">in administering anesthesia to his patients – while he was not on the premises. **

<span style="font-family: 'Courier New',Courier,monospace;">Latosha Lewis and Kareema Cross testified that whatever they did know about medicating patients they had learned from other unlicensed, untrained workers who came before them. Lewis admitted that she was careless about medicating patients until she overmedicated a patient to the point that the patient’s eyes rolled up into her head. She testified that, after that frightening experience, she was more careful to measure when she prepared injections and was more watchful when the patients were medicated.

<span style="font-family: 'Courier New',Courier,monospace;"> In 2008, however, Lewis stopped assisting with the abortion procedures, and Cross stopped in July 2009. Sherry West and Lynda Williams, whom Gosnell hired to take over their duties, were not as conscientious. West had been a long-time patient of Gosnell’s and, according to Cross, she and Lynda Williams both obtained narcotics – Xanax, Oxycontin, promethazine, and Percocet – through Gosnell. According to Lewis, Gosnell hired Sherry West when she lost her job at the Philadelphia Veterans Administration Medical Center after contracting hepatitis C. Yet, despite her hepatitis, West regularly failed to wear gloves when treating patients. In fact, Cross testified that she never saw West wear gloves, even though West worked in the procedure room with the doctor and inserted patients’ IV connections. Cross also said that Williams and West did not know how to give injections correctly, and that patients regularly came in to complain because their arms swelled up after injections as a result of improper technique.

<span style="font-family: 'Courier New',Courier,monospace;"> Even more dangerous was West and Williams’s reckless attitude toward medicating patients. Cross, Lewis, and Ashley Baldwin all described West and Williams as incompetent. Although medicating patients based on a predetermined chart is in itself astonishingly reckless, West and Williams did not even follow the chart when medicating patients. Neither seemed to understand – or care about – the grave risk to patients that their haphazard approach posed. Latosha Lewis testified: “It was a game to them.” Lewis said that when they were supposed to be administering medications, West and Williams were “just goofing off and playing around.”

<span style="font-family: 'Courier New',Courier,monospace;"> According to Kareema Cross, Williams was especially dangerous because she imagined that she was the doctor. Williams seemed to feel it didn’t matter what she did, because Gosnell didn’t care. Cross, Lewis, and Ashley Baldwin all testified that Williams routinely overmedicated patients. This happened because she paid no attention to the chart when she drew up the drugs in a syringe, and because she failed to keep track of or to record what she administered. West, who had told Gosnell that she wasn’t comfortable medicating patients, ended up following Williams’s lead.

<span style="font-family: 'Courier New',Courier,monospace;"> Williams’s habit of using too much medication was so serious that Cross reported it to Gosnell at least a year before Karnamaya Mongar died. Cross got the doctor’s attention by telling him that he was losing money because Williams was using so much medication. As a result, Gosnell put a logbook in the recovery room to keep better track of drugs. This solution, however, was designed to save money, not protect patients. Even if the staff wrote in the logbook, which they frequently did not, they still did not record dosages where it mattered – in the patients’ files. Cross said that Williams did neither.

<span style="font-family: 'Courier New',Courier,monospace;"> Cross testified that she could recall at least 15 times when she had medicated a second-trimester patient only to have Williams come along right behind her and medicate again. Lewis said that no one, including herself, recorded the repeated doses of sedation that the clinic’s staff administered to second-trimester patients to keep them anesthetized throughout their – often six- or seven-hour – wait for the doctor. Lewis was particularly concerned because Williams and West would medicate patients and then not watch them. Even though the clinic had no machines to monitor patients’ breathing or heartbeat, West and Williams would just leave the sedated patients in the back and go out to the front desk to eat and do “other things.” Without the benefit of machines, monitoring at a minimum would require physically watching the patients to make sure they were breathing. Neither Williams nor West did this. Even Kareema Cross admitted that she sometimes did not.

<span style="font-family: 'Courier New',Courier,monospace;"> Indeed, given how the clinic’s practice was set up – with multiple second trimester patients sitting for hours in induced labor, crying in pain, and receiving repeated doses of sedation; with babies precipitating; with no doctor present, and unlicensed staff who showed up only when they felt like it; and with virtually no monitoring equipment – it would have been impossible even for a conscientious staff member to appropriately monitor the patients.

<span style="font-family: 'Courier New',Courier,monospace;"> According to Ashley Baldwin, Williams medicated patients “whenever Sherry told her to,” which was “whenever Sherry felt like somebody needed something.” As for how Williams determined which drugs and how much to give, Ashley answered: “What she thought they needed. She used what she wanted to.” Williams almost never referred to the chart of medications and rarely called the absent doctor for instructions. Ashley testified that Williams used a lot of diazepam and gave repeated doses. (As noted earlier, the high-schooler mixed up diazepam and Demerol elsewhere in her testimony.) Ashley explained that the workers did not usually call to consult with Gosnell because he frequently became angry when they called him.

<span style="font-family: 'Courier New',Courier,monospace;"> In addition to administering drugs to sedate patients, Gosnell’s unlicensed workers also gave second-trimester patients repeated doses of Cytotec to soften their cervixes, stimulate contractions, and induce labor. Most of the staff administered Cytotec by placing a tablet inside the patient’s cheek or lip. But Williams administered it vaginally.

<span style="font-family: 'Courier New',Courier,monospace;"> As Ashley described the situation: Second-trimester patients were in a lot of pain because of all the vaginal Cytotec Williams administered. Williams then administered repeated, heavy doses of sedating drugs to make them “comfortable.” Cytotec causes labor to begin. Women who were given excessive Cytotec would suffer excessive pain as a result. According to Lewis and Cross, the goal of Gosnell’s assistants was to keep the second-trimester patients knocked out during labor and delivery. The doctor was present, if at all, only at the very end of this drug-induced delivery process.


 * <span style="font-family: 'Courier New',Courier,monospace;"> When something went wrong, **

**<span style="font-family: 'Courier New',Courier,monospace;">Gosnell avoided seeking emergency assistance for patients. **
<span style="font-family: 'Courier New',Courier,monospace;">If something went wrong during a procedure – and it inevitably did, given Gosnell’s careless techniques and gross disregard for patient safety – he avoided seeking help. Sherilyn Gillespie, the Department of State investigator who participated in the raid, interviewed a number of former patients whose experiences illustrate Gosnell’s alarming and self-serving practice of covering up life-threatening mistakes, no matter the risk to the patient.

<span style="font-family: 'Courier New',Courier,monospace;">Dana Haynes went to Gosnell for an abortion in November 2006. .... Ms. Haynes required surgery to remove five inches of bowel, needed a large blood transfusion, and remained hospitalized for five days.

<span style="font-family: 'Courier New',Courier,monospace;"> Similarly, Gosnell should have sent another patient, Marie Smith, to the hospital when he was unable to remove the entire fetus during her abortion in November 1999. But again, he just kept the patient waiting, sedated and bleeding in the recovery room while he proceeded with other patients. Again, it was an insistent relative – Marie’s mother – who found her. In Marie Smith’s case, Gosnell did not tell her that he had left parts of the fetus inside her uterus. (Doctors are required to inspect the extracted tissue to ensure they have removed it all.) Instead, Gosnell allowed Marie Smith to go home. When her mother called days later to report that Marie’s condition had worsened, he assured her that Marie would be fine. Fortunately, the mother ignored Gosnell’s assurances and took her daughter to the emergency room. When they arrived at Presbyterian Hospital, Marie was unconscious. Doctors found that Gosnell had left fetal parts inside her and that she had a severe infection. They told her she was lucky to be alive.

<span style="font-family: 'Courier New',Courier,monospace;"> Another patient, a 19-year-old, had to have a hysterectomy after Gosnell left her sitting in his recovery room for over four hours after perforating her uterus. Gosnell finished performing the abortion at 8:45 p.m. on April 16, 1996, but did not call fire rescue until 1:15 a.m. By the time emergency help arrived, the patient was not breathing. She arrived at the Hospital of the University of Pennsylvania in shock, having lost significant blood. To save her life, doctors had to remove her uterus.

<span style="font-family: 'Courier New',Courier,monospace;"> In at least one case, Gosnell prevented a patient’s companion from summoning help. The patient, a recovering addict who was undergoing methadone treatment, started convulsing when Gosnell administered anesthesia. When she fell off the procedure table and hit her head, the staff summoned her companion who was waiting for her. The companion asked Gosnell to call an ambulance, but Gosnell refused. He also prevented the companion from leaving the clinic to summon help.

<span style="font-family: 'Courier New',Courier,monospace;">Tina Baldwin told us that she knew of two or three times that Gosnell perforated a woman’s uterus and then tried to surgically repair these mistakes himself. According to Tina Baldwin, Gosnell did not even tell these patients that he had harmed them.

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell took photographs of his patients’ genitalia **

 * <span style="font-family: 'Courier New',Courier,monospace;">before procedures and collected fetuses’ feet in jars. **

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell engaged in other practices with patients that defy any medical or even common-sense explanation. Steven Massof testified that the doctor would often photograph women’s genitalia before he performed their abortions. According to Massof, Gosnell told him that he was photographing women from Liberia and other African countries who had undergone clitorodectomies, the surgical removal of the clitoris. In his curriculum vitae, Gosnell described this activity as “clinical research: clitoral surgery patients – cultural and functional realities.” There is no evidence, however, that the doctor obtained the necessary permissions to engage in human experimentation.

<span style="font-family: 'Courier New',Courier,monospace;"> Massof said that Gosnell took pictures of women, and of fetuses, with a digital camera and with his phone. Gosnell told Massof that he was taking the photographs for “his teaching,” but Massof said that he was unaware that Gosnell taught anywhere. Gosnell would often show the photographs to Massof and exclaim about the skill of the surgeons who had sewn the women’s labia together, leaving only a small opening to allow menstrual flow.

<span style="font-family: 'Courier New',Courier,monospace;"> Another of the doctor’s practices that defies explanation was his habit of cutting the feet off of aborted fetuses and saving them in specimen jars in the clinic. Kareema Cross showed the Grand Jury photographs she had taken in 2008 of a closet where Gosnell stored jars containing severed feet. During the February 2010 raid, investigators were shocked to see a row of jars on a clinic shelf containing fetal parts. Ashley Baldwin testified that she saw about 30 such jars.



<span style="font-family: 'Courier New',Courier,monospace;"> None of the medical 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 fetal feet were ever used for this purpose.

<span style="font-family: 'Courier New',Courier,monospace;"> **Gosnell operated his clinic with complete disregard for Pennsylvania laws**
<span style="font-family: 'Courier New',Courier,monospace;">**that regulate abortion clinics, health care facilities, and the practice of medicine.** <span style="font-family: 'Courier New',Courier,monospace;">Gosnell flagrantly violated virtually every regulation and law Pennsylvania has relating to the operation of abortion facilities. He did not comply with the basic standards of his profession. Nor did he follow state regulations pertaining to health care facilities generally.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell violated Pennsylvania’s Abortion Control Act in many ways. He failed to counsel patients, despite a requirement to provide counseling at least 24 hours before abortions. He performed abortions on minors without a parent’s consent or a court order.

<span style="font-family: 'Courier New',Courier,monospace;"> He failed to take steps to ascertain accurate gestational ages and he intentionally falsified gestational ages. He did not report to the state Department of Health any of the secondand third-trimester abortions that he performed. Nor did he comply with the Act’s requirement to send tissue from late-term abortions to a pathologist to verify that fetuses were not viable or born alive.

<span style="font-family: 'Courier New',Courier,monospace;"> Many of Gosnell’s violations directly endangered women and caused them serious harm. His contempt for laws designed to protect patients’ safety resulted in the death of Karnamaya Mongar. For example, although Pennsylvania’s abortion regulations, 28 Pa. Code §29.31 et seq., require abortion providers to have functional resuscitation equipment and drugs “ready for use,” Gosnell had no such provisions. The clinic’s one defibrillator, the device used to help revive cardiac arrest patients, had not worked for years. There was only one suction source – the one Gosnell used for the abortion procedures – and no equipment to assist with breathing. And on February 18, 2010, three months after Karnamaya Mongar had died of an overdose of anesthesia, there was no “crash cart” with the drugs necessary to reverse the effects of just such overdoses. Had any of these items been present in the clinic, as the law requires, Mrs. Mongar might be alive.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s facility also lacked equipment legally mandated for monitoring sedated patients. According to Kareema Cross, the clinic owned one old electrocardiogram (EKG) machine to monitor heart rate and a pulse oximeter, an instrument that is attached to the patient’s finger and measures oxygen saturation in the blood, but these had not worked for at least six years. These instruments are the minimum equipment required to monitor patients who are sedated, according to the certified gynecologist and obstetrician who shared his expertise with the Grand Jury. The Department of Health found only one blood pressure cuff in the clinic in February 2010.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s failure to equip his clinic with functioning monitoring and resuscitation instruments was all the more dangerous because of his use of unlicensed workers to perform crucial jobs. State abortion regulations require that women in the recovery room be “supervised constantly” by a registered nurse or a licensed practical nurse under the direction of a registered nurse or a physician. From 2006 until the clinic closed in 2010, Gosnell’s recovery room was often supervised – and not constantly, because she had several other duties – by a high school student, Ashley Baldwin. The state Department of Health documents that, as far back as 1989, Gosnell had no registered or licensed nurses to staff the clinic’s recovery room.

<span style="font-family: 'Courier New',Courier,monospace;"> The complete disregard for patient care was evident in every aspect of Gosnell’s practice. The staff routinely discharged patients before they were fully alert or could even walk. Tina Baldwin described how staff members would discharge still-medicated patients when closing time came:

>> <span style="font-family: 'Courier New',Courier,monospace;"> A: Oh, I did see some people, they were so drugged. I mean you had to get them out, take them with a wheel chair – take them out in a wheelchair. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: And you would just send them on their merry way out the door? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: If it got late, at the time when I was working there, if it got too late like 1:00, 2:00 in the morning and they had a family member, yeah they would go out.

<span style="font-family: 'Courier New',Courier,monospace;"> The state law requires that a second doctor, or a nurse anesthetist, administer general anesthesia, if it is used. General anesthesia is defined by anesthesiologists as a drug-induced loss of consciousness during which patients cannot be aroused, even by painful stimulation, a definition that would include the clinic’s “custom sleep” dosage administered to “knock [patients] out.” Not only did the clinic not have a second doctor administer anesthesia, it did not have any doctor at all present when Ashley Baldwin, Lynda Williams, Sherry West, Tina Baldwin, Latosha Lewis, Kareema Cross, Adrienne Moton, and Steve Massof routinely administered mixtures of potentially lethal drugs to clinic patients.

<span style="font-family: 'Courier New',Courier,monospace;"> Another violation of Pennsylvania law proved significant the night Karnamaya Mongar died: Clinics must have doors, elevators, and other passages adequate to allow stretcher-borne patients to be carried to a street-level exit. Gosnell’s clinic, with its narrow, twisted passageways, could not accommodate a stretcher at all. And his emergency street-level access was bolted with no accessible key. Any chance Mongar had of being revived was hampered by the time wasted looking for keys to the door. Ashley Baldwin testified:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How long was – were the paramedics on-site? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: A long time, because I couldn’t get the key to the lock. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: What happened? Tell the members of the jury what happened. >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Doc told me to get the keys to the locks, but it was like six sets of locks with thirty keys on each one.



**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell routinely performed abortions past Pennsylvania’s 24-week limit. **
<span style="font-family: 'Courier New',Courier,monospace;">Several of the clinic’s former staff told the Grand Jury that Gosnell performed many, many abortions beyond the legal limit in Pennsylvania – a gestational age of 24 weeks. Their testimony is confirmed by clinic files, by fetal remains found at the facility, by photographs of babies that Gosnell delivered and then killed, and by a 30-plus-weeks baby girl born dead at a hospital after Gosnell had inserted laminaria to begin a third-trimester abortion.

<span style="font-family: 'Courier New',Courier,monospace;">Steven Massof estimated that in 40 percent of the second-trimester abortions performed by Gosnell, the fetuses were beyond 24 weeks gestational age. Latosha Lewis testified that Gosnell performed procedures over 24 weeks “too much to count, ” and ones up to 26 weeks “very often.” When Lewis started working at the clinic, 20 first trimester abortions and five or six second-trimester abortions typically were performed per night. But in the last few years, she testified, Gosnell increasingly saw out-of-state referrals, which were all second-trimester, or beyond.

<span style="font-family: 'Courier New',Courier,monospace;"> By these estimates, Gosnell performed //at least// four or five illegal abortions every week. When a detective asked the doctor what percentage of the fetuses – including the first- and second-trimester fetuses – found at the facility during the February 2010 raid were beyond 24 weeks, Gosnell himself estimated “ten or twenty percent at the most.”

<span style="font-family: 'Courier New',Courier,monospace;"> The Philadelphia medical examiner analyzed the remains of 45 fetuses seized from the clinic. Of these, 16 were first-trimester; 25 were second-trimester, ranging from 12 to 21 weeks; 2 were 22 weeks; 1 was 26 weeks; and 1 was 28 weeks. The raid took place on a Thursday, so the clinic’s busiest day for late-term abortions – Saturday – was not included.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s former employees testified that they knew many abortions were performed beyond 24 weeks because they had performed ultrasounds that established gestational ages greater than the 24-week legal limit. When this happened, they would tell Gosnell, and he would often redo the ultrasound, or staff members would be ordered to do so, to produce a different gestational age to record in the patient’s file. Gosnell taught his employees how to manipulate the ultrasound machine to get a false reading – one that would make the fetus appear to be smaller, and younger, than it actually was. Latosha Lewis testified:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Did anybody ever show you how to manipulate an ultrasound? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Who did? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Dr. Gosnell. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: When did he do that? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: I’m not accurate with the dates, but I would say since I’ve been there maybe, the second time I came back ’03, ’04 maybe.

<span style="display: block; font-family: 'Courier New',Courier,monospace; text-align: center;">* * * >> <span style="font-family: 'Courier New',Courier,monospace;">Q: How were you instructed to manipulate the ultrasound and for what purpose? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Basically to manipulate an ultrasound if the woman was laying flat, if you just want an accurate ultrasound, you would just place it on the patient’s stomach and you would measure. >> >> >> <span style="font-family: 'Courier New',Courier,monospace;">If you want to adjust the measurements, you would just lift off the ultrasound a little bit, which you would just make the head look a little smaller. So you would want to measure it, the measurements would be smaller. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: Would that make the gestational age of the fetus younger? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Yes.

<span style="display: block; font-family: 'Courier New',Courier,monospace; text-align: center;">* * * >> <span style="font-family: 'Courier New',Courier,monospace;">Q: For what purpose was that? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: By state law we were only allowed to go up to 24 weeks in a procedure. And a lot of times we would have females that were past 24 and a half weeks. So we manipulate the measurement of the ultrasound, so that indeed that we would try to get the patient to be at the 24-week mark. So we could still perform the procedure even though we were past 24 weeks. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q: How often would he do this? >> <span style="font-family: 'Courier New',Courier,monospace;"> A: Very often.

<span style="font-family: 'Courier New',Courier,monospace;">Lynda Williams told the FBI that “Gosnell dummies paperwork and he will redo ultrasounds over himself to manipulate the image to reflect fetuses at younger ages.” Kareema Cross and Tina Baldwin testified that they also manipulated ultrasound results at Gosnell’s direction. They told of other instances in which Gosnell replaced ultrasound photos that they had put in patient files. If their photos showed a biparietal diameter, a measurement of the fetus’s skull, corresponding to a gestational age above 24 weeks, Gosnell simply substituted a different photo showing a measurement consistent with a younger fetus. Ashley Baldwin testified that she saw Gosnell manipulate ultrasound results himself “a good ten times.”

<span style="font-family: 'Courier New',Courier,monospace;"> Tina Baldwin testified that sometimes Gosnell would manipulate ultrasounds for women who were within the 24-week legal limit so that he could charge them more. “From 15 weeks to 24 weeks then, you’re talking about money and you’re talking about making it, moving it to make it bigger and smaller.” Gosnell charged his patients on a sliding scale based not on gestational age, with late-term abortions sometimes costing $2,500 or more.

<span style="font-family: 'Courier New',Courier,monospace;">Lewis and Massof both testified that they believed Gosnell dealt with some of the patients with the longest-term pregnancies on Sundays, when his staff was not at the clinic. When Massof came in on Monday mornings he would find bloody instruments in the sink even though they had all been cleaned before the facility closed on Saturday night. When Massof asked Gosnell if he had seen patients on Sunday, the doctor answered, according to Massof: “Oh, yes, I took care of it. I had my wife or somebody help me or whatever.” Gosnell’s wife Pearl confirmed that she assisted her husband with procedures on Sundays.

<span style="font-family: 'Courier New',Courier,monospace;"> Steve Massof told the jurors that when the ultrasound showed that the fetus was beyond 24 weeks, the staff would give the chart to Gosnell for him to “counsel” the patient. It is not clear that Gosnell ever counseled these patients. However, he did negotiate the price, because he charged more for women with pregnancies beyond 24 weeks. Latosha Lewis testified that Gosnell would still perform abortions on these patients. She rarely, if ever, saw Gosnell decline to do a procedure because a woman was too far along. Massof said that even if the ultrasound showed a fetus was 24 weeks, it would often be a week or two older by the time the procedure was done because “they would have to get their money.”

<span style="font-family: 'Courier New',Courier,monospace;">Kareema Cross told us, “If it’s a big baby, he [Gosnell] never tell us the truth.” Instead, “He’ll always say the baby was 24.5.” According to his workers, Gosnell recorded any fetus over 24 weeks as “24.5” weeks on their charts. The fetus could be 26 or 28 weeks, but on the chart, the doctor would always write 24.5. They testified that he told them 24.5 weeks was the legal limit. Yet, because Gosnell regularly recorded lateterm abortions as 24.5 weeks, his own notations prove that he performed numerous illegal abortions in violation of Pennsylvania’s 24-week limit.

<span style="font-family: 'Courier New',Courier,monospace;"> Sometimes, where the gestational age exceeded the 24-week limit, Gosnell forgot – or did not bother – to include a manipulated ultrasound in the file. Instead, even where the only ultrasound established a gestational age greater than 24 weeks, Gosnell performed an abortion anyway, indicating, in the patient’s file, that the patient was exactly 24.5 weeks pregnant.

<span style="font-family: 'Courier New',Courier,monospace;"> Law enforcement officers seized some abortion patient files from Gosnell’s clinic. Between the time that law enforcement raided Gosnell’s office in February and the time that investigators returned with a warrant to seize patient files, many files had disappeared. The Grand Jurors viewed a videotape of the February 2010 raid and saw files on shelves outside the procedure rooms and along a hallway. Those shelves and that hallway were empty when investigators returned. Lewis and others told us that these were second-trimester files. Most of the second-trimester files from 2008, 2009, and 2010 remain missing.

<span style="font-family: 'Courier New',Courier,monospace;"> The Grand Jury, reviewing just the fraction of Gosnell’s abortion files seized by authorities, was still able to document numerous instances in which ultrasound readings were manipulated to disguise illegal late-term abortions. Our review, although limited by the disappearance of many patient files, revealed that Gosnell reported performing abortions on 24.5-week fetuses more than 80 times between 2007 and February 2010.

<span style="font-family: 'Courier New',Courier,monospace;"> Clinic staff testified that Gosnell took patients files home and did not keep records of most of his late-term abortions at the clinic. Tina Baldwin explained that Gosnell took second-trimester files home “if there were difficult cases or some cases where he thought they shouldn’t be in there.” Massof told us that Gosnell always took files home, so “I think he has them. If he hasn’t destroyed them, he has them.” A subsequent search of Gosnell’s home and car turned up only some of these files. One of the files seized from Gosnell’s car was partially shredded.

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell caused a 30-week baby to be stillborn. **
<span style="font-family: 'Courier New',Courier,monospace;"> The vast majority of Gosnell’s post-24-week abortions we learned of from files. But there were some that came to the attention of other doctors and hospitals that were called on to treat his patients. This is how the Grand Jury learned of one third-trimester viable fetus that Gosnell caused to die before it was born. He did so by initiating an abortion on a 14-year-old girl who is estimated to have been 30 weeks pregnant. The teenager came to Gosnell for an abortion in September 2007. ....

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell began an abortion on a 29-week pregnant woman **

 * <span style="font-family: 'Courier New',Courier,monospace;">and then refused to take dilators out when the woman changed her mind. .... **

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s illegal practice was a huge moneymaker. **
<span style="font-family: 'Courier New',Courier,monospace;"> Clinic workers’ testimony gave the jurors an idea of how profitable Gosnell’s abortion business was. Maddline Joe, an employee of Gosnell’s for nearly 20 years and office manager for the last two and a half, said that in the early years, the clinic averaged 20 first-trimester and 5 or 6 second-trimester patients a night. In the last few years, she said, the first-trimester business was down to 10 to 15 patients a night. As the first trimester business dropped off, according to Latosha Lewis, Gosnell began to do more very late-term abortions, often on out-of-state patients. These, Lewis said, brought in a lot of money.

<span style="font-family: 'Courier New',Courier,monospace;">Lynda Williams provided the FBI with a handwritten chart listing what Gosnell charged for abortions at various gestational ages:

>> <span style="font-family: 'Courier New',Courier,monospace;"> 6 weeks - 12 weeks $330 >> <span style="font-family: 'Courier New',Courier,monospace;"> 13 weeks - 14 weeks $440 >> <span style="font-family: 'Courier New',Courier,monospace;"> 15 weeks - 16 weeks $540 >> <span style="font-family: 'Courier New',Courier,monospace;"> 17 weeks - 18 weeks $750 >> <span style="font-family: 'Courier New',Courier,monospace;"> 19 weeks - 20 weeks $950 >> <span style="font-family: 'Courier New',Courier,monospace;"> 21 weeks - 22 weeks $1,180 >> <span style="font-family: 'Courier New',Courier,monospace;"> 23 weeks - 24 weeks $1,625

<span style="font-family: 'Courier New',Courier,monospace;"> But other employees said that what he charged was often more. They said he charged as much as $3,000 for a single late-term abortion. The great aunt of another patient testified that she paid $2,500.

<span style="font-family: 'Courier New',Courier,monospace;"> Even using conservative estimates, the amount of money that Gosnell took in every procedure night is staggering. If he did 20 first-trimester abortions at $330 a piece, and five 19- to 20-week abortions at $950, he would take in $11,350 a night. Similarly, in the later years, if he performed 10 first-trimester and 5 late-second-trimester (23 to 24 <span style="font-family: 'Courier New',Courier,monospace;"> weeks) abortions a night, Gosnell would still take in $11,425. And that does not include any of the illegal abortions past 24 weeks for which he charged much more, or the profits he made by selling additional anesthesia a la carte to first-trimester patients. This amounts to nearly $1.8 million a year – almost all of it in cash – assuming just three procedure nights a week. (Testimony indicated that he performed abortions from about 8:00 p.m. to 1:00 a.m., three nights a week – for a total of 15 hours.) In light of the testimony we heard that Gosnell performed the really late third-trimester abortions on Sundays, his take was likely much higher. And none of this includes his income from writing prescriptions – according to one law enforcement agent, Gosnell was one of the top three Oxycontin prescribers in the state of Pennsylvania.


 * <span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s criminal enterprise was not limited to illegal late-term abortions; **

**<span style="font-family: 'Courier New',Courier,monospace;">he also conspired to defraud patients, **

 * <span style="font-family: 'Courier New',Courier,monospace;">insurance companies, and a nonprofit that provides financial assistance for abortions. **

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell committed a variety of frauds. He defrauded his patients by charging them for appointments with Steve Massof and Eileen O’Neill under the pretense that they were real doctors. Kareema Cross testified that this sometimes caused confusion with patients and hospitals. She said that the clinic would receive calls when patients reported to a hospital that they had been treated or sent to the hospital by “Dr. O’Neill.” When no one at the hospital could find a record of a Dr. O’Neill, the patient would call to find out her first name. Cross said that the staff were instructed to say that O’Neill was a student and that Massof was a resident. The patients were told to use Gosnell’s name even if they thought they were patients of “Dr. O’Neill” and “Dr.” Steve. By defrauding patients, Gosnell, O’Neill, and Massof could charge for doctors’ appointments even when no licensed physician was present.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell also defrauded insurance companies. For example, although Gosnell was not an approved provider for Keystone East Health Insurance subscribers, this did not stop him and O’Neill from treating Keystone East subscribers and charging the insurer for their services. According to Randy Hutchins and others, Gosnell simply asked Dr. Agnes Simmons, a fellow West Philadelphia doctor, who was a Keystone provider, to pretend that she worked at the Women’s Medical Society so that the clinic could bill Keystone under her name.

<span style="font-family: 'Courier New',Courier,monospace;">Maddline Joe, the office manager in charge of submitting insurance forms, claimed, unconvincingly, that Dr. Simmons saw some patients at Gosnell’s clinic. But no other worker, including the receptionist, Tina Baldwin, ever saw Dr. Simmons working at the clinic. Randy Hutchins testified that he learned that Gosnell would split insurance payments on these claims with Dr. Simmons.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell defrauded the Delaware Pro-Choice Medical Fund as well. This organization provides financial assistance to Delaware women seeking abortions. Gosnell tapped into the Delaware fund by falsely claiming that some of his patients lived in Delaware. Ashley Baldwin explained that she would call the Fund for Gosnell:

>> <span style="font-family: 'Courier New',Courier,monospace;"> Q. Did you have a lot of Delaware patients come to Philadelphia? >> <span style="font-family: 'Courier New',Courier,monospace;"> A. No. He used to lie. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q. What do you mean ‘he used to lie’? >> <span style="font-family: 'Courier New',Courier,monospace;"> A. About the Philly addresses. He would change their address to a Delaware address so he could get paid for them. >>>> <span style="font-family: 'Courier New',Courier,monospace;">* * * >> <span style="font-family: 'Courier New',Courier,monospace;">He would write the price that he want on there. And I would have to call. . . and get an okay and a confirmation number, and then the money would be sent to him. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q. But these people didn’t have anything to do with Delaware? >> <span style="font-family: 'Courier New',Courier,monospace;"> A. No. >> <span style="font-family: 'Courier New',Courier,monospace;"> Q. They didn’t live in Delaware or have anything to do in Delaware? >> <span style="font-family: 'Courier New',Courier,monospace;"> A. No.

**<span style="font-family: 'Courier New',Courier,monospace;"> A national association of abortion providers declined to admit the Women’s Medical Society **

 * <span style="font-family: 'Courier New',Courier,monospace;">as a member, finding it to be the worst facility its inspector had ever seen. .... **

<span style="font-family: 'Courier New',Courier,monospace;"> To the jurors, the most appalling thing revealed by the NAF review is not that Gosnell tried to bluff his way through the application process with a borrowed nurse and some new lounge chairs. It is that he made no effort to address the grave deficiencies in his practice that had caused Karnamaya Mongar’s death.

**<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s contemptuous disregard **

 * <span style="font-family: 'Courier New',Courier,monospace;">for the health, safety, and dignity of his patients continued for 40 years. **

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell’s disregard for his patients’ safety was nothing new. The Pennsylvania Department of Health has records as far back as the 1980s documenting Gosnell’s dangerous practices. For decades, Gosnell did not staff his facility with licensed or qualified employees. He never properly monitored women under sedation. He botched surgeries and then failed to summon emergency help when it was needed. His entire practice showed nothing but a callous disdain for the lives of his patients. As far back as 1972, he was notorious for his mistreatment of the women who came to him for treatment.

<span style="font-family: 'Courier New',Courier,monospace;"> Randy Hutchins testified that Gosnell told him about what has been called the “Mother’s Day Massacre.” ....

<span style="font-family: 'Courier New',Courier,monospace;"> According to Hutchins, Gosnell told him that he left Pennsylvania for an extended period after the super coil incident. First he went to the Bahamas, and then to New York. Hutchins explained Gosnell’s reasoning:

>> <span style="font-family: 'Courier New',Courier,monospace;"> If the State Board of Medicine hadn’t brought any charges against you, all right, and you were away long enough, you could come back and your license was still considered to be in good standing.

<span style="font-family: 'Courier New',Courier,monospace;"> Gosnell was apparently correct. The Pennsylvania Board of Medicine ignored his role in this grotesquely unsuccessful experiment, which seriously and permanently maimed several women. The Board overlooked Gosnell’s unprofessional conduct not only in the 1970s but for the next three decades, as he continued to employ unlicensed workers to practice medicine at his clinic, and as his patients continued to suffer serious injuries or worse during abortion procedures.