How+Did+This+Go+On+So+Long?

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.

**Summary: a brief look at how Gosnell was able to continue his dangerous and illegal practices, despite many governmental organizations that were supposed to provide oversight.**

Section VI: How Did This Go On So Long?

The callous killing of babies outside the womb, the routinely performed third trimester abortions, the deaths of at least two patients, and the grievous health risks inflicted on countless other women by Gosnell and his unlicensed staff are not the only shocking things that this Grand Jury investigation uncovered. What surprised the jurors even more is the official neglect that allowed these crimes and conditions to persist for years in a Philadelphia medical facility.

===THE STATE DEPARTMENT OF HEALTH NEGLECTED ITS DUTY TO ENSURE THE HEALTH AND SAFETY OF PATIENTS IN PENNSYLVANIA’S ABORTION CLINICS. ===

We discovered that Pennsylvania’s Department of Health has deliberately chosen not to enforce laws that should afford patients at abortion clinics the same safeguards and assurances of quality health care as patients of other medical service providers. .... The Board's attorneys had ample notice of Gosnell's illegal and reckless abortion practices.... Eight years before Karnamaya Mongar died, a former Gosnell employee told the Department of State about the illegal practice that resulted in Mrs. Mongar's death.... Yet ... the Board too no action to suspend or revoke his license.

===PENNSYLVANIA’S DEPARTMENT OF STATE NEGLECTED ITS DUTY TO DISCIPLINE A DOCTOR ENGAGED IN UNPROFESSIONAL CONDUCT. ===

 The Department of Health was not the only state agency that could and should have shut down Gosnell decades ago. ....

===THE PHILADEPHIA DEPARTMENT OF PUBLIC HEALTH ALSO IGNORED ALARMING WARNINGS ABOUT GOSNELL’S PRACTICE. ===

 Marcella Choung was not the only person to report Gosnell’s appalling medical practice to health officials. An employee of the Philadelphia Department of Public Health alerted her bosses – twice – that things were seriously wrong at Gosnell’s clinic. The last time she did so was one month before Karnamaya Mongar died. Records produced by the city department reveal that employees in at least two different divisions within the department missed red flags that should have led to investigation and action. Supervisors in the Division of Disease Control ignored a nurse’s disturbing report about conditions in Gosnell’s clinic in 2008 and 2009. ....

FELLOW DOCTORS WHO OBSERVED THE RESULTS OF GOSNELL’S RECKLESS AND CRIMINAL PRACTICES FAILED TO REPORT HIM TO AUTHORITIES.
 Pennsylvania’s Abortion Control Act requires any doctor who treats a woman because of a complication arising from an abortion to make a report to DOH. Willful failure to do so constitutes “unprofessional conduct” and subjects the treating doctor to sanctions by the Board of Medicine. Clearly, this law is being violated, if not willfully, at least consistently. ....

WHO COULD HAVE PREVENTED ALL THIS DEATH AND DAMAGE?
Had state and local officials performed their duties properly, Gosnell’s clinic would have been shut down decades ago. Gosnell would have lost the medical license that he used to inflict irreparable harm on women; to illegally abort viable, late-term fetuses; and to kill innumerable babies outside the womb.

Had DOH treated the clinic as the ambulatory surgical facility it was, DOH inspectors would have assured that the staff were all licensed, that the facility was clean and sanitary, that anesthesia protocols were followed, and that the building was properly equipped and could, at least, accommodate stretchers. Failure to comply with these standards would have given cause for DOH to revoke the facility’s license to operate.

 If inspectors had looked solely for violations of Pennsylvania’s abortion regulations, there would have been ample grounds to revoke the approval of Gosnell’s clinic as an abortion provider – as was demonstrated when DOH inspectors finally entered the facility in February 2010.

 Had state inspectors reviewed patient files, they would inevitably have noticed that Gosnell was routinely performing abortions without informed consent from patients or signed consent from parents. His files revealed that he was performing numerous illegal abortions at “24.5 weeks,” in itself a confession of criminality. Gosnell, moreover, almost never had the required pathology reports for second-trimester abortions.

 Had DOH inspectors spoken to the workers, they might well have discovered that Gosnell’s procedure included severing the spinal cords of babies born alive. Revoking his approval to perform abortions would have been simple. But no one from DOH set foot in Gosnell’s clinic for over 16 years.

<span style="font-family: 'Courier New',Courier,monospace;"> The Department of State prosecutors did not even need to go looking for reasons to revoke Gosnell’s medical license. Complaints came to them. Marcella Choung, the former Gosnell employee, spelled out his entire criminal operation for them. Complaints of perforated uteruses and bowels; of a patient’s death from a botched procedure that resulted in a $900,000 settlement; and of family members physically barred from summoning emergency help, were all sent to Department of State attorneys. Yet the department considered none of these complaints serious enough to take action against Gosnell.

<span style="font-family: 'Courier New',Courier,monospace;"> Had the Philadelphia Department of Public Health reported to state officials all that its employees knew or suspected about filthy facilities, fraud, the unlicensed practice of medicine, anesthesia chosen by patients based on cost, infectious waste improperly handled and stored, and vaccines stored next to medical waste, perhaps state authorities would have taken action against Gosnell and Women’s Medical Society.

<span style="font-family: 'Courier New',Courier,monospace;"> And had fellow doctors, the ones who treated the women after Gosnell butchered them, demanded the attention of DOH and the Board of Medicine, that too might have made a difference.

<span style="font-family: 'Courier New',Courier,monospace;"> We don’t know. We only know what happened when none of these people did what they should have.