Gosnell – Abortion Clinic Conditions

Gosnell

CLINIC CONDITIONS:

*Dirty facilities; unsanitary instruments; an absence of functioning monitoring and resuscitation equipment; the use of cheap, but dangerous, drugs; illegal procedures; and inadequate emergency access for when things inevitably went wrong, all put patients at grave risk – every day.

*Gosnell and his staff showed consistent disregard not only for the health and
safety of their patients, but also for the laws of Pennsylvania. After reviewing extensive
and compelling evidence of criminal wrongdoing at the clinic, the Grand Jury has issued
a presentment recommending the prosecution of Gosnell and members of his staff for
criminal offenses including:
• Murder of Karnamaya Mongar
• Murders of babies born alive
• Infanticide
• Violations of the Controlled Substances Act
• Hindering, Obstruction, and Tampering
• Perjury
• Illegal late-term abortions
• Violations of the Abortion Control Act
• Violations of the Controlled Substances Act
• Abuse of Corpse
• Theft by Deception
• Conspiracy
• Corrupt Organization
• Corruption of Minors

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.”

*The Women’s Medical Society was filthy and totally unsuitable as a medical office or a surgical facility. 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.

*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.

FEB 18,2010 Search Team for RAID:

*The search team waited outside until Gosnell finally arrived at the clinic, at about 8:30 p.m. When the team members entered the clinic, they were appalled, describing it to
the Grand Jury as “filthy,” “deplorable,” “disgusting,” “very unsanitary, very outdated, horrendous,” and “by far, the worst” that these experienced investigators had ever
encountered. There was blood on the floor. A stench of urine filled the air. A flea-infested cat was wandering through the facility, and there were cat feces on the stairs. Semi-conscious women scheduled for abortions were moaning in the waiting room or the recovery room, where they sat on dirty recliners covered with blood-stained blankets.

Aborted Remains Flushed Down the Garbage Disposal
• Hampton testified about her cleaning duties, which included the large bottle on the suction machine that would fill with blood and fetal remains during first trimester abortions. She testified that she would dump the blood contents of the bottle into a wash sink located between procedure rooms then turn on the garbage disposal – the same one present in the court room as evidence – and grind and flush the contents down the drain. It is illegal in Pennsylvania to dispose of bloody remains in this way.
• It was above that same wash sink that Crime Scene Unit Officer Taggart testified he discovered several jars containing the severed feet of aborted babies.
Body parts flushed down the toilet

• Johnson worked as a janitor, maintenance man and plumber of sorts and he was the common-law husband of 51-year-old Elizabeth Hampton, who is herself Gosnell’s wife’s sister. He told jurors some of the morbid details that appear in the grand jury report — including how he threatened to quit working at the abortion clinic because he refused to pull any more flesh from aborted babies out of the plumbing. …He told the jury toilets backed up one-two times a week and said he opened the outside clean out pipe and fetal parts such as babies’ arms came spilling out.Johnson said he scooped up body parts with shovel and put them in a bag that was taken to rat infested basement. Johnson said a cat kept at the Gosnell clinic was there to deal with rat infestations that kept happening. He said the [cat] pooped in plants all over clinic.
• The abortion could take as long as three days, one staffer admitted in it.
• “If … a baby was about to come out, I would take the woman to the bathroom, they would sit on the toilet and basically the baby would fall out and it would be in the toilet,” testified Latosha Lewis, who worked for Gosnell for over eight years. “I would be rubbing her back and trying to calm her down for two, three, four hours until Dr. Gosnell comes. She would not move.”
• According to the report, “[Johnson] described how he had to lift the toilet so that someone else—he said it was too disgusting for him—could get the fetuses out of the pipes.”If the unborn baby hadn’t “fallen out” by the time Gosnell was able to attend to the woman, staff would push and shove on the women’s abdomen.“By maximizing the pain and danger for his patients, [Gosnell] minimized the work, and cost, for himself and his staff,” states the report. “The policy, in effect, was labor without labor.”

ABORTIONS PAST 24 WEEK LEGAL LIMIT:

Gosnell BABY A

Gosnell routinely performed abortions past Pennsylvania’s 24-week limit
*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.

*Gosnell routinely performed abortions beyond the 24-week limit. He was ruthless in severing the spinal cords of viable babies outside their mothers’ wombs. This conduct
clearly constitutes prosecutable criminal behavior. In order for district attorneys to be able to prosecute, however, the crimes must first be detected. This is DOH’s job – to
ensure that violations of Pennsylvania health care laws are detected. Its inspectors must review files as part of their inspections. They must look at ultrasound tests and pathology reports on second-trimester fetuses. They must make sure that informed and parental consent forms have been signed and that abortions have been reported to DOH.
Instead, Pennsylvania officials have created what amounts to an honor system, a system conspicuously lacking in regulatory oversight or enforcement. If DOH abdicates its responsibility to monitor and inspect abortion clinics, the protections that the Abortion Control Act provides to prematurely born infants and unborn post-24-week fetuses become meaningless to those willing to break the law. The wrongful death of a viable fetus is deemed a homicide. DOH must ensure that the law is applied to protect those
least able to protect themselves.

ANESTHESIA:

Patients received multiple, heavy doses of sedatives that kept them anesthetized for several hours with no licensed medical professional on the premises.

• 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.

• *Latosha Lewis described the same standard procedures as Cross 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.

The workers Gosnell hired were incompetent and uncaring in administering anesthesia to his patients – while he was not on the premises.

• *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.”

• *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.

• *Ashley explained that the workers did not usually call to consult with Gosnell because he frequently became angry when they called him.


ANIMALS/FECIES/URINE /FOUL SMELL :

• [ Former Employees] * 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.

• “The clinic reeked of animal urine, courtesy of the cats that were allowed to roam (and defecate) freely.”
• Cat feces on the stairs/ flea Infested Cats
• *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.

BATHROOMS NOT CLEAN:
• [Former Employee] *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.

Gosnell exam-chair-gal

BLOOD STAINS:

• Crime Scene Unit officer John Taggart was cross examined by McMahon about the condition of the clinic and the furnishings. Taggart admitted that he had never tested any of what he thought were blood smears and stains found throughout the clinic to prove the substance was in fact blood. He explained that at a normal crime scene, blood would be tested to determine if it belonged to the victim or the perpetrator. In the Gosnell case, there had been no need to determine who the blood belonged to, so it was not tested. Cameron then asked Taggart to test the apparent blood stains on the equipment in the courtroom, including smears on a dirty gray recliner seized from the clinic’s recovery room.
COVER-UPS:
• *Gosnell and his staff tried to cover up what drugs were administered, who administered them, when, and how. The evidence indicates that Sherry West made false entries on Mrs. Mongar’s file before handing it over to the Hospital of the University of Pennsylvania. Ashley Baldwin testified that the paramedics asked for Mrs. Mongar’s file so they could take it with them to the hospital. Instead of giving it to them, Ashley said, West grabbed the chart and took it herself to the hospital. By the time the file was turned in to the hospital doctors, it had notations about medications that Ashley said had not previously been there [See Appendix D]. The notations were totally inconsistent with all of the other evidence – from Lynda Williams, from Mrs. Gurung, and even from Gosnell – and grossly understated the amount of medication that was given… What Gosnell and others reported to the hospital, to the Health Department, and to law enforcement about the amount of medication they gave to Mrs. Mongar was demonstrably false.

EMERGENCY EQUIPMENT : NO RESCECITATION EQUIPMENT: CRASH CART/EKG
• *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 a ny of these items been present in the clinic, as the law requires, Mrs. Mongar might be alive.

• *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.
• *There was no functioning resuscitation or even monitoring equipment, except for a single blood pressure cuff in the recovery room.
• A crash cart was present in court that was discovered under a bed in Gosnell’s house. There was no crash cart found inside his clinic.
• Ashley Baldwin said she was in the clinic on the night Mongar went into cardiac arrest. She said Gosnell was pumping on Mongar’s chest and called to her to plug in a defibrillator. “I got a small shock when I plugged it in,” Baldwin added. “It didn’t work.”

Gosnell emergency-door-gal (1)
EMERGENCY EXIT LOCKED
• A locked emergency exit at the clinic. Paramedics who arrived to transport Karnamaya Mongar to the hospital needed access to this door in order to get a stretcher into the clinic, but, according to the Grand Jury report, clinic staff could not find the keys.

ms-Mongar
• *Ambulances were summoned to pick up the waiting patients, but (just as on the night Mrs. Mongar died three months earlier), no one, not even Gosnell, knew where the
keys were to open the emergency exit. Emergency personnel had to use bolt cutters to remove the lock. They discovered they could not maneuver stretchers through the
building’s narrow hallways to reach the patients (just as emergency personnel had been obstructed from reaching Mrs. Mongar).

• Gosnell sent Ashley to the front desk to look for the key, but she could not find it. Ashley told us that a firefighter needed to cut the lock, but “It took him awhile … because the locks is old.” She testified that it took “twenty minutes, probably trying to get the locks unlocked.” Mrs. Gurung and her mother-in-law ran outside, crying. Mr. Ghalley and Mrs. Gurung, frightened, watched the firefighters struggling to get the door open, while Karnamaya Mongar lay motionless. After cutting the locks, responders had to waste precious more minutes trying to maneuver through the narrow cramped hallways that could not accommodate a stretcher.

REFUSED AMBULANCES:
• *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. (See also PATIENTS SHEET)


EMPLOYEES – DID AS THEY WERE TOLD:

gosnell9_20110120163405_320_240

Gosnell employee MORTON
Adrienne Moton , “I kept doing whatever I was told,” she told the jury last week.
GosnellSherryWEST
Sherry West, “I felt a loyalty to him because he had been my doctor for so long,” West testified.

Elizabeth Hampton – During the FBI investigation of the clinic, Hampton said that she wasn’t “totally truthful” with investigators because she was scared. She was later arrested for perjury in August 2010 and pleaded guilty. After the investigation, Elizabeth Hampton said that Gosnell ordered the employees to clean and scrub the clinic. The first floor was repainted. When asked why he did so, Hampton replied “If he said to do something, we did it. We didn’t question him.”
LindaWilliams
Lynda Williams told investigators she only snipped a neck the one time, “because it gave me the creeps.”“I only do what I’m told to do,” she told the jury. “What I was told to do was snip their neck.”

• ASHLEY BALDWIN: “They looked just like regular babies,” Baldwin said. Baldwin said one baby was so big that Gosnell joked that “this baby is going to walk me home.” She said the joke bothered her and she talked to her mother about it. Baldwin’s mother, however, was also a Gosnell employee. Tina Baldwin had worked there since 2001. Ashley Baldwin said she assisted Gosnell in abortions, applying pressure to the mother’s abdomen, handing the doctor instruments and equipment. She said she also saw Gosnell use scissors to “snip” the neck of newborns who were moving after the procedure. Although she sometimes felt uneasy about what she saw, Baldwin said, Gosnell always had an explanation: “He told me that’s how it was supposed to go.”

procedure-room-gal

EQUIPMENT
ULTRASOUND MACHINE OLD:
• Dr. Karen Feisullin, a practicing ObGyn at a major metropolitan hospital testified that another piece of equipment in the courtroom, the ultrasound machine, was so old that she had never seen one like it. She put on latex gloves before picking up the abdominal and vaginal transducers, which were discolored and filthy. Feisullin testified that she was not even sure where the monitor screen was on the ancient device.

EQUIPMENT: Broken equipment / OUTDATED
In this photo of a procedure room at the clinic, corrosion can be seen on the osygen tank tubing.

*Medical equipment – such as the defibrillator, the EKG, the pulse oximeter, the blood pressure cuff – was generally broken; even when it worked, it wasn’t used.


FAILED TO GAIN CONSENT:

• *Mrs. Mongar’s initials, perhaps written by someone else, appear on a form entitled “Consent to Office Procedure Administration of Anesthesia and Rendering of Other Medical Services.” This form purported to authorize Gosnell or “whomever he may designate as his assistant” to perform a therapeutic abortion. Unspecified anesthesia was to be administered “by or under the direction of one of the staff members.” The form included a waiver of “any claim that my consent is not informed consent.” This consent form and waiver were supposedly initialed by the non-English-speaking patient. Her daughter, who also spoke almost no English, was asked to sign as a witness.

FAILED TO REPORT AB’s TO STATE:
• 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.

Gosnell biohazard-bags-gal

FETAL PARTS STORED IN BLDG FOR YEARS:
• *The search team discovered fetal remains haphazardly stored throughout the clinic
– in bags, milk jugs, orange juice cartons, and even in cat-food containers
Gosnell freezer-gal
• Some fetal remains were in a refrigerator, others were frozen.
• *scattered throughout, in cabinets, in the basement, in a freezer, in jars and bags and plastic jugs, were fetal remains. It was a baby charnel house.
• Bags and bottles holding aborted fetuses were scattered throughout the building.
• Jars containing the severed feet of babies lined a shelf.
• Investigators found fetal bodies and body parts in garbage bags, plastic boxes, and bottles at the clinic, the report said.
• A search of Gosnell’s office, called the Women’s Medical Society, in West Philadelphia revealed that bags and bottles holding aborted fetuses were scattered throughout the building. Jars containing the severed feet of babies lined a shelf. Furniture and equipment was dusty, broken, and blood-stained.

• It took the medical examiner, Dr. Gulino, five days just to catalog the containers of fetal parts and the examiner also examined feet and lower extremity found in jars of formaldehyde belonging to five babies Gosnell killed. The ages of the unborn children ranged from first trimester to 22 weeks and the latter baby was possibly viable. “Most fetuses he examined were found in cat food, other containers. Frozen in red plastic bags,” Sullenger said. “He never encountered situation before and attempted to get guidance. This case was “unprecedented” he said.”

Gosnell freezer-gal


BABIES STORED IN FRIG:

• *The Philadelphia Department of Public Health does not regulate doctors or medical facilities; but it is supposed to protect the public’s health. Philadelphia health department employees regularly visited the Women’s Medical Society to retrieve blood samples for testing purposes, but never noticed, or more likely never bothered to report, that anything was amiss. Another employee inspected the clinic in response to a complaint that dead fetuses were being stored in paper bags in the employees’ lunch refrigerator. The inspection confirmed numerous violations of protocols for storage and disposal of infectious waste. But no follow-up was ever done, and the violations continued to the end.

Gosnell feet1-300x178

JAR OF SEVERED FEET:
• *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. 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 waspreserving 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.

*The investigators found a row of jars containing just the severed feet of fetuses. In the basement, they discovered medical waste piled high. The intact 19-week fetus
delivered by Mrs. Mongar three months earlier was in a freezer.

• One of the most bizarre things about this case is Dr. Gosnell’s fetal foot collection. He cut the feet off the fetuses he aborted and kept them in a row of jars. No civilized society can accept such an abomination, whether the fetuses in question were viable or not…
• [Page 74] 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 [click to enlarge]…

• *We heard evidence that Gosnell often mutilated dead babies and fetuses by cutting off their feet, which he, weirdly, kept in specimen jars in the clinic. During the February 2010 raid, investigators were shocked to see a row of jars on a shelf in the clinic containing fetal parts. Kareema Cross showed us several photographs that she took in 2008 of a closet where Gosnell stored jars containing severed feet of fetuses. Ashley Baldwin testified that she saw about 30 such jars. None of the medical or abortion experts who testified before the Grand Jury had ever heard of such a disturbing practice, nor could they come up with an explanation for it. The medical expert on abortions testified that cutting off the feet “is bizarre and off the wall.” The experts uniformly rejected out of hand Gosnell’s supposed explanation that he was preserving the feet for DNA purposes should paternity ever become an issue. A small tissue sample would suffice to collect DNA. None of the staff knew
• The following severed feet and a fetus without feet were discovered in the 2010
raid:
The feet of a 22-week fetus in specimen containers that the
medical examiner referred to as 4C-1 and 4C-2. These
containers were labeled with the same name and the date
12/5/09. Each foot was in a separate container. The medical
examiner found with respect to each foot that “the distal portion
of the leg has been sharply transected 2.5 cm above the sole of
the foot.”
A 21-week fetus, gender indeterminate, found in a plastic bleach
bottle, wrapped in red biohazard bag 3F. The medical examiner
discovered that “Both feet have been severed at the level of the
distal leg and are not present in the container.”
The left foot of a 19-week fetus in specimen container 4B.
According to the medical examiner, “The distal portion of the
leg has been sharply transected 2.7 cm. above the sole of the
foot.”
The feet of a 19-week fetus in specimen containers 5B-1 and 5B-
2. As to the left foot, the medical examiner found, “The distal
portion of the leg has been sharply transected 2.5 cm. above the
sole of the foot in an oblique fashion.” As to the right foot, “the
distal portion of the leg has been sharply transected 1.9 cm.
above the sole of the foot in an oblique fashion.”

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

FETAL POC’S NOT SENT TO PATHOLIGIST:

• *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.)

FORCED ABORTIONS –
• *We were particularly appalled by the reference in the form to a decision being “forced” on a patient by a partner or parents.. As long as he was paid, the patient’s
wishes or circumstances were not his concern.
• In December 2001, Marcella Stanley Choung had filed a detailed, written complaint with the Pennsylvania Department of State. Among her allegations.. Gosnell performed abortions on “underage children” against their will if their mothers asked him to; and that he performed other abortions without consent forms…According to the files turned over to the Grand Jury by the Department of State, no further action was taken until April 29, 2004 – nearly two years later – when Greenwald, the same prosecuting attorney who recommended against following up on Semika Shaw’s death, also recommended closing the case on Choung’s allegations

FRAUD:

DEFRAUDED PATIENTS:
• *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.

Defrauded insurance companies

• *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.

• 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.

DEFRAUDED Delaware Pro-Choice Medical Fund

• 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.

HALLWAYS TOO NARROW:

• *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.
• *Ambulances were summoned to pick up the waiting patients, but (just as on the night Mrs. Mongar died three months earlier), no one, not even Gosnell, knew where the
keys were to open the emergency exit. Emergency personnel had to use bolt cutters to remove the lock. They discovered they could not maneuver stretchers through the
building’s narrow hallways to reach the patients (just as emergency personnel had been obstructed from reaching Mrs. Mongar).

INFECTIOUS DISEASE
• *A doctor from Children’s Hospital of Philadelphia hand-delivered a complaint, advising the department that numerous patients he had referred for abortions came back from Gosnell with the same venereal disease.

• *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. 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. 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.

MEDICAL RECORDS NOT PRIVATE:

• A simultaneous search of Gosnell’s house found patient files that he had taken from the clinic. In a filing cabinet in his 12-year-old daughter’s closet, they found
$240,000 in cash and a gun.

• Della Mann, a registered nurse who had worked at the clinic years earlier , and had become a patient, said that in 2008, she decided to stop going to Gosnell’s office because of its reckless handling of patient files. She said that the files were left all over the place and that anyone, including other patients, could have access to them.

• *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.

biohazard-bags-gal
MEDICAL WASTE NOT DISPOSED OF PROPERLY
• *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.

• 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.

• *On May 7, 2004, a city health department inspector was sent to the clinic. His report stated that

1. proper labels were missing from areas where waste was stored
2. that red bag containers for infectious waste were not lidded
3. that marked boxes of infectious waste were sitting on the basement floor – not raised as they should be
4. that red bags for pick-up were not properly stored in the basement
5. the clinic did not provide a contract with a disposal company. Gosnell subsequently produced some more paperwork, including a copy of a contract for disposal. However, he never paid his fee.

The city never approved his medical waste plan. And he never cleaned up the infectious waste. Yet five years later, he was still operating. When the Grand Jurors toured the facility in 2010, boxes of waste were still sitting on the basement floor. Gosnell still stored aborted fetuses in plastic containers in the freezer. Employees described a stench emitted by bags of fetal tissue that piled up in the clinic… according to what Dr. Schwarz was told, sometime in 2004 or 2005 – shortly after Davis sent to the clinic the form letter reminding delinquent medical providers to submit their waste plans and pay their fee – the department stopped trying to enforce the regulation against those who had not complied.

IMPROPER DISPOSAL:

Gosnell biohazard-bags-gal
This photo shows bags of biohazard in the basement of the clinic. According to the report, Gosnell had arranged for a weekly pickup of biohazardous materials, but because he failed to pay his bills, the materials piled up in the basement.

DISPOSAL:

Taggart testified that last Friday he returned to the clinic and retrieved one final item which was also in court. It was a large garbage disposal that was under the sink in the wash room that was between the O’Keefe and Monet abortion rooms where jars containing the severed feet sat on a shelf. When asked why the garbage disposal was brought to court,


MEDICATE/SLAP UNRULY PATIENTS:

• *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:
A: . . . He would ask you what her temperament was, you know.
Q: Why did it matter what her temperament was?
A: I don’t know. He would just ask you what it was, you
know, what she was doing.
Q: For instance, if someone was carrying on, really crying out in pain –
A: Oh, you would knock them out completely.
Q: Why?
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.
Q: So he would just drug a girl in the back if she was complaining and carrying on?
A: If she was out of hand, yeah, she would get put under.
Q: How often would that happen?
A: Any time somebody got out of hand.
Q: How often would people get out of hand?
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.
Q: And there’s other patients there with her, right?
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 getdone first.

• *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.

MEDICATIONS IMPROPERLY STORED:
• *The City of Philadelphia employee who did notice and report the abysmal conditions she observed at Gosnell’s clinic was a registered nurse named Lori Matijkiw.
Matijkiw conducted what the Health Department calls an “AFIX” visit, or vaccine inspection, in July 2008. On July 16, 2008, at 1:30 p.m., Matijkiw made a vaccine inspection visit to Gosnell’s clinic. Unlike the inspectors before her, she did not simply stick to her narrow, assigned task of inspecting vaccines and their storage units. She took seriously her broader duty to protect public health. Following her visit to Gosnell’s facility, she reported on a multitude of deficiencies she found….She noted that the office was “not clean at all, and many areas of the office smell like urine.” She reported a “dark layer of dust” on the baseboards and described the “enormous” fish tanks, filled with murky water. In the refrigerator, she found expired vaccines – one with an expiration date of March 2006, another 2005. The temperature log, which was supposed to record the refrigerator temperature every day, had not been marked since the second day of June – a month and a half earlier. On top of the refrigerator, she found a stack of temperature logs, already filled out, showing readings twice a day, with no initials, time, or month. Matijkiw wrote that Tina Baldwin showed her to a freezer in a “lab” (quotation marks are in the original email) on the second floor. Inside she found “3-4 large plastic containers with blood-colored frozen contents, wrapped in blue chux.” She described a “red fluid spilled/frozen on the floor of the freezer.” Chicken pox vaccines were stored in an ice tray above the containers of bloody fetuses.

MEDICATION OUTDATED

• *All the women had been sedated by unlicensed staff – long before Gosnell arrived at the clinic – and staff members could not accurately state what medications or dosages
they had administered to the waiting patients. Many of the medications in inventory were past their expiration dates.

MEDICINE ADMINISTERED BY UNLICENSED STAFF
Gosnell sedation-chart-gal

A sedation dosage chart drawn by Ashley Baldwin, a 15-year-old girl who worked at the clinic alongside her mother, Tina Baldwin.
• *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.
• Ashley’s color-coded chart described the various levels of sedation that Gosnell
provided, and the mix of drugs that comprised them, as follows:
 Local (10 mg. of nalbuphine and 12.5 mg. of promethazine);
 Heavy (50 mg. Demerol, 12.5 mg. promethazine, and 5mg. diazepam);
 Twilight (75 mg. Demerol, 12.5 mg. promethazine, and 7.5 mg. diazepam); and
 Custom (75 mg. Demerol, 12.5 mg. promethazine, and 10 mg. diazepam).

• Latosha Lewis described how she and the other unlicensed staff members presented the choice of medication to the clinic’s patients: 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.

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

*Gosnell had unlicensed and unsupervised staff routinely administer potent and dangerous drugs when he was not present at the clinic.

• 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. 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.

• The doctor himself was seldom present. In his absence, untrained, unsupervised workers, one of them a teenage girl, routinely injected dangerous sedatives into women undergoing illegal late-term abortions.
• *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.

• *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.” 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.”

• *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.

Cytotec
• *The person at the front desk, usually the unlicensed and untrained longtime employee Tina Baldwin, would start medicating the patients by giving them more Cytotec to induce labor and temazapan (Restoril) to make them sleepy. The doctor did not arrive before 8:00 pm or later, despite the fact that patients frequently began arriving at noon.
For hours after they came to the clinic, patients were left naked from the waist down (the clinic provided no robes, only blankets that were washed once a week).
Women sat in bloodstained lounge chairs in the “recovery room” while unlicensed, unsupervised workers gave them large doses of various drugs. Cytotec was administered hourly, or whenever the staff got around to it. Pills of either 100 mg. strength or 200 mg. – the workers were unclear what they were giving -were administered both buccally, that is, by placing them in the patient’s cheek or lip, or vaginally. These frequent doses of Cytotec made the women’s uteruses contract and cramp, throwing them into active labor and causing severe pain. Kareema Cross, a coworker of Lewis’s, testified that as the patients got “bigger and bigger” over the years, the workers would give more and more Cytotec.
OVER MEDICATE:

• *To make the patients “comfortable” – and keep them quiet – the clinic’s unlicensed and untrained workers used butterfly needles for IV access and injected
several different strong, sedative drugs into the women and girls in order to, as Latosha Lewis and Kareema Cross put it, “knock them out.” All afternoon and evening, as patients woke and complained of pain, workers would continue to medicate them with injections of sedatives. Between doses, the staff would leave patients largely untended. This would go on until the doctor arrived, some six or more hours after the patient did, or until the woman delivered.

PATIENTS LEFT UNSUPERVISED:
• 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.


NOT MONITORED:

• Lynda Williams testified that they never hooked patients up to monitoring devices to check their pulse, heartbeat or breathing and the one monitoring machine they had in Gosnell’s clinic never worked. Williams said she monitored patients by simply looking at them and watching for a pulse in their neck veins.

PRO-CHOICE COMMUNITY KNEW OF CONDITIONS:
• We have learned during our investigation that Gosnell’s reckless ways were not unknown to people in the community. Some pro-choice and women’s health groups learned from Gosnell’s patients of their frightening experiences. Patients reported that they were put totally to sleep for long periods of time, that they were treated badly, and that the facility was dirty. The community groups tried to help women file complaints. They were unsuccessful, however, in part because the complaint form used by the Department of State – the same form that one would use to complain about a barber or a car salesman – is difficult to fill out, especially if the complainant is not well educated or does not speak English. It demands considerable personal information, and it does not guarantee confidentiality for medical records. When representatives of one of the organizations tried to file a complaint with the Board of Medicine on behalf of the women, they were allegedly told that they could not file a third-party complaint.

PRESIGNED PRESCRIPTION FORMS /PILL MILL:

*By day it was a prescription mill; by night an abortion mill. A constant stream of “patients” came through during business hours and, for the proper payment, left with scripts for Oxycontin and other controlled substances, for themselves and their friends. Gosnell didn’t see these “patients”; he didn’t even show up at the office during the day. He just left behind blank, pre-signed prescription pads, and had his unskilled, unauthorized workers take care of the rest. The fake prescriptions brought in hundreds of thousands of dollars a year.

PROFIT:

A price list for procedures. Former employee Kareema Cross testified, “[for] 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.” Abortions past the gestational age of 24 weeks are illegal in Pennsylvania.

A price list for sedation packages. According to the report, Gosnell made at least $1.8 million per year, in addition to the money he made writing prescriptions. Authorities say Gosnell was one of the top three prescribers of Oxycontin in Pennsylvania.
• The real business of the “Women’s Medical Society” was not health; it was profit.. With abortion, as with prescriptions, Gosnell’s approach was simple: keep volume high, expenses low – and break the law. That was his competitive edge.. At the Women’s Medical Society, the only question that really mattered was whether you had the cash. Too young? No problem. Didn’t want to wait? Gosnell provided same-day service… Gosnell catered to the women who couldn’t get abortions elsewhere – because they were too pregnant… But for Dr. Gosnell, they were an opportunity. The bigger the baby, the more he charged… Gosnell prepared a list of preset dosage levels to be administered in his absence. But no allowances were made for individual patient variations, or for any monitoring of vital signs. All that mattered was the money. The more you paid, the more pain relief you received.

• *A simultaneous search of Gosnell’s house found patient files that he had taken from the clinic. In a filing cabinet in his 12-year-old daughter’s closet, they found
$240,000 in cash and a gun.
• *Gosnell ran a criminal enterprise, motivated by greed… Gosnell recklessly cut corners, allowed patients to choose their medication based on ability to pay, and provided abysmal care – all to maximize his profit.

• *We estimate that Gosnell took in as much as $10,000 to $15,000 a night, mostly in cash, for a few hours of work performing abortions. And this amount does not include
the money he made as one of the top Oxycontin prescribers in the state.

• The only thing Gosnell seemed to care about was the cash he raked in from his illegal operation.

• *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.

• *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.

• *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.”

• Charged for abortions at various gestational ages:
 6 weeks – 12 weeks $330
 13 weeks – 14 weeks $440
 15 weeks – 16 weeks $540
 17 weeks – 18 weeks $750
 19 weeks – 20 weeks $950
 21 weeks – 22 weeks $1,180
 23 weeks – 24 weeks $1,625
• *Gosnell charged as much as $3,000 for a single late-term abortion.

• *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 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.
• Pictures were also presented to the jury showing Gosnell’s
 two large homes,
 his boat
 private boat dock
 his newer model F150 extended cab pickup truck.
 a photo of his gaudy deep purple bedroom at his Philadelphia home was revealing. In it belongings were strewn about and piled everywhere, and appeared much as one would expect a hoarder’s house to look, and resembled the general junky appearance of his abortion clinic rooms.
• Authorities found $250,000 in cash under a mattress when they raided his home in 2010, although they believe he also made significant sums through a separate “pill mill” at his street-corner clinic, where they say a steady stream of people sought painkiller prescriptions.

• Patients were allowed to choose any level of sedation, as long as they paid for it. 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.


OUT OF STATE PATENTS:

• He couldn’t get doctors to refer patients because of his declining reputation. So he increasingly relied on attracting women from out of state. He even provided a bed in the clinic for overnight stays, the grand jury report said.
• Gosnell began to rely much more on referrals from other areas where abortions as late as 24 weeks are unavailable. More and more of his patients came from out of state and were late second-trimester patients. Many of them were well beyond 24 weeks. Gosnell was known as a doctor who would perform abortions at any stage, without regard for legal limits. His patients came from several states, including Delaware, Maryland, Virginia, and North Carolina, as well as from Pennsylvania cities outside the Philadelphia area, such as Allentown. He also had many late-term Philadelphia patients because most other local clinics would not perform procedures past 20 weeks.

REUSED UNSANITARY INSTRUMENTS ON PATIENTS
NOT STERILIZED:
• *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.

REUSED CURETTES

• *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.

SEXUAL ABUSE:

• Gosnell took photographs of his patients’ genitalia before procedures *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. 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 allow menstrual flow. (Page 76 Grand Jury Report)

ULTRASOUND DECEPTION:
• *Gosnell’s solution was simply to fudge the measurement process. Instead of hiring proper ultrasound technicians, he “trained” the staff himself, showing them how to aim the ultrasound probe at an angle to make the fetus look… smaller. If one of his workers nonetheless recorded an ultrasound measurement that was too big, it would just be redone. Invariably these second ultrasounds would come in lower. In fact, almost every time a second ultrasound was taken, the gestational age would be recorded as precisely 24.5 weeks – slightly past the statutory cutoff. Apparently Gosnell thought he would get away with abortions that were just a little illegal. In reality, of course, most of these pregnancies were considerably more advanced.

MANIPULATE ULTRASOUNDS:

• *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… 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.” 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.

UNLICENSED STAFF –
• *The people who ran this sham medical practice included no doctors other than
Gosnell himself, and not even a single nurse. Two of his employees had been to medical
school, but neither of them were licensed physicians. They just pretended to be.
Everyone called them “Doctor,” even though they, and Gosnell, knew they weren’t. Among the rest of the staff, there was no one with any medical licensing or relevant
certification at all. But that didn’t stop them from making diagnoses, performing
• procedures, administering drugs.

UNLICENSED STAFF PERFORMED ABORTIONS/ULTRASOUNDS/EXAMS:

• *While there was no doctor on the premises during the day, the clinic’s unlicensed assistants saw abortion patients beginning at about 10:00 a.m. Women could walk in for
ultrasounds and for what the clinic staff called “pre-exams.” During the pre-exam, which cost $125, one of the clinic’s workers would ask the patient about her past medical
history, allergies, and last menstrual period. The staff member would also draw blood, take the woman’s blood pressure, and perform an ultrasound to determine the age of the
fetus – even though none of the staff was properly trained to do ultrasounds. The clinic worker would have the patient sign the facility’s consent form (rarely if everreviewing it with the client), and then schedule the procedure.

• *Gosnell staffed his abortion clinic with unlicensed and unqualified workers. Gosnell deliberately hired unqualified staff because he could pay them low wages,
often in cash. Most of Gosnell’s employees who worked with patients had little or no remotely relevant training or education. Nor did they have any certifications or licenses to
treat patients. Yet they did so regularly, and without supervision – in violation of Pennsylvania’s medical practice standards and the law.
• *Tina Baldwin testified that certification did not matter to Gosnell. He told his workers that there was a “grandfather clause where if you – since he’s a doctor and he
taught you, you could be automatically whatever it is he taught you to be. You could be certified because he taught you to do that.”
Gosnell employed a high school student to medicate and monitor abortion patients

• *In September 2006, Gosnell hired Ashley Baldwin, Tina’s daughter, to work at his clinic when she was just 15 years old…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.
By her senior year, Ashley was doing just about everything in the clinic except performing surgeries.

• *Ashley Baldwin was 15 when she began working for Gosnell, she testified:” 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.” 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…Based on this “training,” Ashley would draw up the medications for as many as20 patients a night….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.”

DELIVERY W/O DOCTOR PRESENT:

• *Very often, the patient delivered without Gosnell being present. Lewis testified
that one or two babies fell out of patients each night. They dropped out on lounge chairs, on the floor, and often in the toilet. If the doctor was not there, it was not unusual for no one to tend to the mother or the baby. In fact, several of the clinic’s workers refused to deal with the expelled babies or the placenta. So, after delivering babies, women and girls would have to just sit and wait – sometimes on a toilet for hours – for Gosnell to arrive.

• Lewis acknowledged that she would not do anything but wait with the women:
“A lot of times this happened when [Gosnell] wasn’t there. If . . . a baby was about to come out, I would take the woman to the bathroom, they would sit on the toilet and basically the baby would fall out and it would be in the toilet and I would be rubbing her back and trying to calm her down for two, three, four hours until Dr. Gosnell comes. She would not move.”


UNSTERILE CONDITIONS:

*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.

SUCTION TUBING/ CANNULAS

• The same corroded suction tubing used for abortions was the only tubing available for oral airways if assistance for breathing was needed.
• OPERATION RESCUE: Gosnell had two abortion rooms where he gave poor women abortions that were small, cramped, cluttered, and dirty. They were called the Monet Room and the O’Keefe Room after the cheap painting reproductions that hung in each. Taggart had gathered furniture and objects from the clinic and brought them to the courtroom. Each piece of equipment was identified, including a box of cloudy yellowish plastic disposable cannulas that had been repeatedly reused.
• A cannula is the sharp plastic tube that attaches to the suction machine which enters the womb to suction out an early-term baby. It is also used to suction out the amniotic fluid in later abortions and to clean out the remaining tissue after the abortion is completed.

*Investigators found the clinic grossly unsuitable as a surgical facility.

The two surgical procedure rooms were filthy and unsanitary – Agent Dougherty described them
as resembling “a bad gas station restroom.”

• Instruments were not sterile.
• Equipment was rusty and outdated.
• Oxygen equipment was covered with dust, and had not been inspected.
• The same corroded suction tubing used for abortions was the only tubing available for oral airways if assistance for breathing was needed.
• There was no functioning resuscitation or even monitoring equipment, except for a single blood pressure cuff in the recovery room.
• Ambulances were summoned to pick up the waiting patients, but
• Instruments were not properly sterilized.
• Disposable medical supplies were not disposed of; they were reused, over and over again.
• 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.
• Furniture was dusty, broken, and blood-stained
• Furniture and blankets were stained with blood.
• Smell of Urine
• Animal Feces and litter boxes in rooms
• “filthy, deplorable, and disgusting”
• Blood on the floor
• blood-stained blankets;
• Filthy Rooms: Accused of performing procedures in filthy rooms some of the rooms had litter boxes and animals present at the time of the operations;
• Reusing unsanitary instruments

*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.” 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.”

[Former Gosnell employees]
*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.

Stains and tears are seen on this examination table in the procedure room. According to the testimony of former employee Kareema Cross, “The rooms were dirty. Blood everywhere. Dust everywhere. Nothing was clean.”

IGNORED STATE REQUIREMENTS – the 24-hour waiting period
MANIPULATE ULTRASOUNDS:
PERFORMED SAME DAY ABORTIONS
REFUSED AMBULANCES: ( See Patients)
Semiconscious women moaning in the waiting or recovery rooms
*When two of Gosnell’s staff members sought abortions, they knew better than to go to him. They went to other clinics, where they marveled that physicians actually counseled patients, the facilities appeared sanitary, and a doctor was in the room when they were medicated.

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