Gosnell Grand Jury Excerpts: “The travesty, from this Grand Jury’s perspective, is that the Department of Health could and should have closed down Gosnell’s clinic years before”
By Dave Andrusko
This excerpt from the Grand Jury’s report gives an overview of all
the ways Kermit Gosnell’s Women’s Medical Society abortion clinic was in
violation of basic safety standards; how this was known for years and
years by those with authority to make him comply or close him down; and
when Gosnell’s abortion clinic was shut down it was not because of the
Department of Health finally did its job but because law enforcement
discovered the horrendous conditions when it raided the clinic looking
for evidence that Gosnell was illegally selling prescription drugs.
________________________
Department of Health [DOH] evaluators found multiple grounds to
shut down the Women’s Medical Society once they finally entered the
facility.
It was not until February 18, 2010, when DOH representatives were
escorted in by law enforcement agents, that they finally inspected the
clinic that they had not bothered to visit in 13 years. This time,
neglecting the horrors at 3801 Lancaster Avenue was no longer an option.
Over the next few days, the DOH evaluators identified a multitude of
violations of the Abortion Control Act and abortion regulations, many of
which were apparent with even a cursory glance around the facility. ….
When patients are sedated to the point of being deeply asleep, as
they were when Gosnell performed second-trimester abortions, additional
equipment is required. Even when the sedation is less deep – a level
referred to as conscious sedation, in which the patient can still
respond to verbal instructions – Pennsylvania regulations require that
additional equipment be readily available, including a “monitor
defibrillator with electrocardiogram visual display of heart rate and
rhythm” (ECG) and a pulse oximeter.
Women’s Medical Society effectively had none of this. A document
filed by DOH on March 12, 2010, referred to as an “Order to Show Cause,”
laid out several grounds for shutting the clinic. It stated that the
only items on the list that were in the facility in any form were
suction and oxygen sources and an unusable monitor defibrillator and
ECG. Yet there was only one suction source for each procedure room,
meaning that the same suction source used to perform the abortion would
have to be used to resuscitate patients. The DOH document noted,
moreover, that neither suction machine had an inspection sticker to
indicate that it was functioning properly. The suction tubing on both
machines was corroded, according to the report.
As for the supposed oxygen sources, DOH noted:
One oxygen source was an E cylinder oxygen tank that lacked a label to indicate whether the tank was full or empty. The oxygen mask and tubing hanging from the tank were covered in a thick ray layer of a substance that appeared to be dust. … The other oxygen source at the … facility was an oxygen concentrator covered with a thin layer of dust. The oxygen concentrator bore no inspection sticker and no evidence of inspection to assure proper functioning. There was no oxygen mask or tubing with the oxygen concentrator.
The DOH document stated that the monitor defibrillator and ECG not
only had no inspection sticker, but was unusable because there were no
electrodes to attach to the machine. Latosha Lewis testified that the
machine had been broken for at least six years.
As the DOH Order to Show Cause noted in “Count I,” each time
Gosnell performed a procedure without the required equipment and drugs
for resuscitation, he violated the abortion regulations §29.33(1). He
also violated §29.33(4) by failing to have a doctor certified by the
American Board (or Osteopathic Board) of Obstetrics and Gynecology
either on staff or available as a consultant. (Count II.) The Department
of Health also cited the clinic for failing to conduct or to record
required lab tests in violation of §29.33(6). (Counts III and IV.)
After entering Gosnell’s facility with law enforcement agents, DOH
representatives reviewed the files of some of its patients (some of whom
were present and had procedures on February 18, 2010, when the search
was conducted; and some of whom had had procedures in the previous few
months). Nine of the patients had had second-trimester abortions. Under
Pennsylvania’s abortion regulations, abortion providers are required to
send any tissue from second-trimester procedures to a pathologist to
determine whether there is evidence of viability. Gosnell had failed to
do this for any of the nine patients, thus violating §29.33(8) nine
times. (Count V.)
The Department of Health also charged Gosnell’s clinic with failing
to have written procedures and policies for the administration of
anesthesia and for failing to maintain a list of employees permitted to
administer it. These failures constituted violations of §29.33(12).
(Count VI.) Other violations detailed by DOH in March 2010 were the
failure to have patients in recovery monitored by a registered nurse or a
licensed practical nurse, or to have such nurses enter the doctor’s
orders in the patients’ medical records as required by §29.33(13).
(Counts VII and VIII.)
The DOH document stated (in Count IX) that the clinic violated
§29.33(14) of the abortion regulations by failing to have corridor doors
and passages adequate in size and arrangement to allow a
stretcher-borne patient to be moved from each procedure room and
recovery room to a street-level exit. DOH noted that ambulance crews on
February 18, 2010, had wanted to evacuate two patients from Gosnell’s
clinic on stretchers, but instead had to help them walk through the
corridors. The situation was made even worse because the closest exit
door to the street was padlocked shut, and the staff could not find the
key.
Count X alleged that Gosnell failed to ensure that one of the
patients having an abortion on February 18, 2010, had a private
consultation regarding the necessity of her abortion, as required by
§29.32. Count XI stated that the clinic failed to report the death of
Karnamaya Mongar within 24 hours as required under 40 Pa.C.S.
§1303.313(a) (the Medical Care Availability and Reduction of Error, or
MCARE, Act).
Count XII spelled out a violation of §29.38(a)(5) of the abortion
regulations, which requires doctors to file a “Report of Complication”
with DOH any time they treat a patient as a result of a complication
from an abortion. The complication that Gosnell treated, but allegedly
did not report, was the cardiac arrest suffered by Karnamaya Mongar.
Count XIII accused the clinic of violating §29.38(5), which
requires abortion providers to file quarterly reports with DOH, stating
the number of abortions performed by the facility in each trimester of
pregnancy. The most recent report filed by Gosnell’s clinic stated that
it had performed 118 first-trimester and 2 second-trimester abortions in
the fourth quarter of 2009. But even in the few files that DOH
evaluators reviewed in February 2010, there were six second-trimester
procedures performed in the last two months of 2009.
The last count in the DOH document – Count XIV – cited the failure
to file reports on every abortion performed, as required by §29.38(3).
Specifically, DOH stated that Gosnell did not file reports on six of the
women whose files DOH reviewed in February 2010. This failure violated
the abortion regulations and constituted grounds for revoking DOH
approval to perform abortions. Indeed, each of the violations enumerated
by the DOH Order to Show Cause constitutes grounds for revoking the
clinic’s approval to perform abortions under §29.43(d) – many times
over, in fact. Once the DOH inspectors entered the facility in February
2010, they did a thorough job of inspecting Gosnell’s clinic and moved
quickly to revoke its “approval,” based on the clinic’s many flagrant
violations of law.
The travesty, from this Grand Jury’s perspective, is that DOH could
and should have closed down Gosnell’s clinic years before. Many, if not
all, of the violations cited in the March 12, 2010, document had been
present for nearly two decades. The violations had been apparent when
DOH site-reviewers, including Susan Mitchell and Janice Staloski,
inspected the facility in 1989, 1992, and 1993. Yet it was not until law
enforcement discovered the horrendous conditions inside 3801 Lancaster
Avenue that DOH took action to close the clinic.
Source NRLC News
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