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"The state Department of
Health failed to investigate Gosnell's clinic even in response
to complaints" Part Three of Four Editor's note. This excerpt is from an almost unbelievable report by a Philadelphia Grand Jury. Abortionist Kermit Gosnell is charged with eight counts of murder. We are running a excerpt from the 261-page report each and every day. According to DOH [Department of Health] witnesses, sometime after 1993, DOH instituted a policy of inspecting abortion clinics only when there was a complaint. In fact, as this Grand Jury's investigation makes clear, the department did not even do that. Janice Staloski, one of the evaluators of Gosnell's clinic in 1992, 10 years later was the Director of DOH's Division of Home Health – the unit that is inexplicably responsible for overseeing the quality of care in abortion clinics. In January 2002, an attorney representing Semika Shaw, a 22-year-old woman who had died following an abortion at Gosnell's clinic, wrote to Staloski requesting copies of inspection reports for any on-site inspections of the clinic conducted by DOH. Staloski wrote to the attorney that no inspections had been conducted since 1993 because DOH had received no complaints about the clinic in that time. Except that it had. In 1996, another attorney, representing a different patient of Gosnell's, informed Staloski's predecessor as director of the Home Health Division that his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell's negligence. The Home Health director discussed this patient with DOH Senior Counsel Kenneth Brody, and the complaint report was documented in records turned over to the Grand Jury. It was surely available to Staloski when she inaccurately told the attorney in January 2002 that DOH had received no complaints regarding Gosnell's clinic. Not documented in the records turned over to the Grand Jury was a second complaint registered between 1996 and 1997. This one was hand-delivered to the secretary of health's administrative assistant by Dr. Donald Schwarz, now Philadelphia's health commissioner. Dr. Schwarz, a pediatrician, is the former head of adolescent services at Children's Hospital of Philadelphia and was the directing physician of a private practice in West Philadelphia. For 17 years, he treated teenage girls from the West Philadelphia community. Occasionally, he referred patients who wanted to terminate their pregnancies to abortion providers. Gosnell's clinic was originally included as a provider in the referral information that Dr. Schwartz gave to his patients. He and his physician partners noticed, however, that patients who had abortions at Woman's Medical Society [Gosnell's abortion clinic in West Philadelphia] were returning to their private practice, soon after, infected with trichomoniasis, a sexually transmitted parasite, that they did not have before the abortions. When this happened repeatedly, Dr. Schwartz sent a social worker to talk to people at Gosnell's facility. Based on the social worker's visit to Women's Medical Society, Dr. Schwartz stopped referring patients to the clinic. He also hand-delivered a formal letter of complaint to the office of the Pennsylvania Secretary of Health. Dr. Schwartz told the Grand Jury that he does not know what happened to his complaint. He never heard back from DOH. And the department did not include it in response to the Grand Jury's subpoena requesting all complaints relating to Gosnells' clinic. We know that no inspection resulted. We are very troubled that state health officials ignored this respected physician's report that girls were becoming infected with sexually transmitted diseases at Gosnell's clinic when they had abortions there. If Dr. Schwarz's complaint did not trigger an inspection, we are convinced that none would. We also do not understand how a report of this magnitude was not at least added to Gosnell's file at the state department of health. It suggests to us that there may have been many more complaints that were never turned over to the Grand Jury. We heard testimony from DOH officials who should have been aware of Dr. Schwarz's complaint – Kenneth Brody and Janice Staloski, at least. Yet they made no mention of it to the Grand Jury. Did they remember the complaint and choose to exclude it from their testimony? Is ignoring complaints of this seriousness so routine at DOH that they honestly do not remember? Or did the secretary of health never even forward it on for action? Of these possible explanations, we are not sure which is the most troubling. In addition to these two complaints filed in 1996 and 1997, Staloski herself received two inquiries from attorneys' offices about Gosnell's clinic in the first two months of 2002. One was from the Shaw family's attorney. The other was from a paralegal for yet a third attorney who phoned her on February 6, 2002, asking for information concerning the clinic. Surely these two inquiries in 2002 should have alerted Staloski that there were complaints from at least two people about the clinic, complaints serious enough to warrant civil attorney's involvement. Yet she ordered no investigation of the clinic, even though it had not been site-reviewed in nine years. In 2007, Dr. Frederick Hellman, the Medical Examiner for Delaware County, reported to DOH the stillbirth of a 30-week-old baby girl. A medical examiner investigator, Irene LaFlore, made the phone calls. She spoke to several DOH employees, including Brody, the senior counsel. The investigator reported to the DOH officials that the medical examiner had conducted an autopsy on the stillborn baby delivered by a 14-year-old girl at Crozier-Chester Medical Center. She explained that the baby's delivery had been induced in the course of an abortion performed by Gosnell, and the medical examiner was concerned because performing an abortion at 30 weeks was a clear violation of the Abortion Control Act. According to the investigator's notes, Brody suggested that the medical examiner inform the District Attorney's Office in Delaware County – for possible referral to Philadelphia, where the procedure occurred – because it was a crime to perform an abortion beyond 24 weeks. Brody said that neither DOH nor the state medical board had any authority over the matter. The senior counsel did ask the investigator to keep him informed. The investigator's notes suggest Brody told her that, once the district attorney acted, then the medical board could get involved. Brody was correct to refer Dr. Hellman to the district attorney to prosecute the abortion of the 30-week pregnancy a crime. That, however, did not absolve DOH of its responsibility. The information provided by Dr. Hellman's investigator should have been received as a complaint to DOH. The department should have initiated an investigation. DOH could have revoked the clinic's license without waiting for a criminal prosecution that might never (and did not) happen. Yet no one from the department went to investigate Gosnell's clinic. Since February 2010, Department of Health officials have reinstituted regular inspections of abortion clinics--finding authority in the same statue they used earlier to justify not inspecting. [Evaluator Janice] Staloski blamed the decision to abandon supposedly annual inspections of abortion clinics on DOH lawyers, who, she said, changed their legal opinions and advice to suit the policy preferences of different governors. Under Governor Robert Casey, she said, the department inspected abortion facilities annually. Yet, when Governor Tom Ridge came in, the attorneys interpreted the same regulations that had permitted annual inspections for years to no longer authorize those inspections. Then, only complaint-driven inspections supposedly were authorized. Staloski said that DOH's policy during Governor Ridge's administration was motivated by a desire not to be "putting a barrier up to women" seeking abortions. [DOH Senior Counsel Kenneth] Brody confirmed some of what Staloski told the Grand Jury. He described a meeting of high-level government officials in 1999 at which a decision was made not to accept a recommendation to reinstitute regular inspections of abortion clinics. The reasoning, as Brody recalled, was: "there was a concern that if they did routine inspections, that they may find a lot of these facilities didn't meet [the standards for getting patients out by stretcher or wheelchair in an emergency], and then there would be less abortion facilities, less access to women to have an abortion." Brody testified that he did not consider the "access issue" a legal one. The Abortion Control Act, he told the Grand Jurors, charges DOH with protecting the health and safety of women having abortions and premature infants aborted alive. To carry out this responsibility, he said, DOH should regularly inspect the facilities. Nevertheless, the position of DOH remained the same after Edward Rendell became governor. Using the legally faulty excuse that the department lacked the authority to inspect abortion clinics, Staloski left them unmonitored, presumably with the knowledge and blessing of her bosses, Deputy Secretary Stacy Mitchell and a succession of Secretaries of Health. The department continued its do-nothing policy until 2010, when media attention surrounding the raid of the Gosnell clinic exposed the results of years of hands-off "oversight." Now, once again, the regulations, which have never been modified, apparently allow for regular inspections. This is, and always was, the correct position. The state legislature gave DOH the duty to enforce its regulations; the authority and power to do so are implicit in that duty. The department abandoned this responsibility without explanation, and without notice to the public or the legislature. … Without regular inspections providers like Gosnell continue to operate; unlawful and dangerous third-trimester abortions go undetected; and many women, especially poor women, suffer. These are all consequences of DOH's abdication of its responsibility. Moreover, even if Staloski was instructed not to conduct regular, annual inspections, that does not explain why she failed to order inspections when complaints were received. It is clear to us that she was made aware, numerous times, that serious incidents had occurred at Gosnell's clinic. These incidents, which evidenced alarming as well as illegal long-standing patterns of behavior, warranted investigation. Yet, in all the years she worked at the department, Staloski never ordered even one inspection |