Gosnell Timeline – what took the state so long to inspect this house of horrors?

TIMELINE: Information from GRAND JURY QUOTE and other sources

DrKermitGosnell

1960’s METH CLINIC: Walter Edmonds, a childhood friend-Edmonds later helped Gosnell open a methadone clinic on 38th Street called the Mantua Halfway House, as well as an abortion clinic on 36th Street. Sidney H. Schnoll recalled being recruited by Gosnell to volunteer at the drug clinic when both were medical residents at Jefferson in the late 1960s. His methadone clinic once employed 25 people, Edmonds said, before it unraveled. State tax liens piled up against the clinic through the 1980s and 1990s, and it folded. Edmonds, who ran Gosnell’s methadone clinic but left on bad terms, said he was dismayed by the news about Gosnell, but not entirely surprised -even by the detail that Gosnell kept the feet of fetuses in jars. “It sounded like him,” he said. Gosnell “always operated outside of the norm. Wherever the boundary was, he just sort of reached beyond .”

1966– Graduated Med School – moved briefly to New York City to work at an abortion clinic, learning early-term techniques in the days before the U.S. Supreme Court’s Roe v. Wade decision formally legalized the procedure.

1970’s – early 1970s, Gosnell had married his first wife, a nurse, and had two children

1970’s – Although Dr. Gosnell was never trained as an obstetrician-gynecologist, he began doing abortions at another clinic in the 1970s.

1972– he played a prominent role in a scandal over an experimental abortion tool called “the super coil,” designed for use in the second trimester. California psychologist and activist Harvey Karman had developed the coil. Gosnell tested it on 15 poor women who had taken a bus from Chicago on Mother’s Day weekend because they couldn’t get abortions elsewhere. Federal and city health officials later found that nine of the women had suffered serious complications, including a punctured uterus. One needed a hysterectomy.

1972- made national headlines –and prompted a federal investigation –for using an experimental abortion inducing device similar to an IUD on 15 low-income women, nine of whom developed serious complications. Dr. Gosnell was never charged in those cases. (2)
From the start, he was well-known for being willing to do abortions beyond 12 weeks –the limit set by many clinics –and for treating poor and minority women. (2)

1979– He opened his Women’s Medical Society at 38th Street and Lancaster Avenue in 1979.

1979 – Gosnell abortion CLINIC OPENS

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The Department of Health first granted approval for the Women’s Medical Center to provide abortions at 3801 Lancaster Avenue on December 20, 1979. The approval followed an on-site review and was good for 12 months. The DOH “site review” at the time identified a certified obstetrician/gynecologist, Joni Magee, as the medical director,
with Gosnell listed as a staff physician. The report noted that a registered nurse worked two days a week, four hours a day, and that lab work was sent out to an outside
laboratory.

pearl gosnell
FIRST INSPECTION – *The Pennsylvania Department of Health had contact with the Women’s Medical Society dating back to 1979, when it first issued approval to open an abortion clinic. 1979- Pennsylvania Department of Health approval to do abortions at his clinic in 1979, after an on-site inspection. (2)

1980’s – *Randy Hutchins was the only licensed medical provider, other than Gosnell, to work with any regularity at the clinic in the last several years. However, it was not lawful for him to perform the duties assigned by Gosnell because Gosnell did not obtain the State Board of Medicine’s approval, as required. Hutchins testified that he worked for Gosnell for a year in the 1980s but left after he stole money from the doctor. Hutchins explained that he had a cocaine problem at the time. He returned to work at the clinic in July 2009 partially because Gosnell was willing to allow him to work off the debt. From August until the middle of September, Hutchins said, “I really didn’t get paid.” Hutchins normally worked Mondays, Tuesday, and Fridays. His primary job was to see “pain management” patients. However, his name also appeared on Karnamaya Mongar’s records on Wednesday, November 18, 2009. Her chart shows that Hutchins inserted laminaria the night before her procedure. Hutchins quit in February 2010, before the raid, because Gosnell never filed the paperwork required to allow him to work legally.

1982– PEAL HIRED, Pearl Gosnell, the doctor’s third wife, also helped out in the office. Pearl assisted with abortion procedures on Sundays and days the clinic was normally closed. She
worked at the clinic as a full-time medical assistant from 1982 until she married Gosnell
in 1990.

1989– *The Pennsylvania Department of Health did not conduct another site review until 1989, ten years later. Numerous violations were already apparent, but Gosnell got a pass when he promised to fix them.

*As far back as 1989, and again in 1993, the Pennsylvania Department of Health cited him for not having any nurses in the recovery room. Gosnell ignored the warnings and the law. He just paid his fines and knowingly continued the dangerous practice of employing unqualified personnel to administer dangerous drugs. It was his modus operandi.

1990– GOSNELL MARRIES Pearl Gosnell, the doctor’s third wife, also helped out in the office. Pearl assisted with abortion procedures on Sundays and days the clinic was normally closed. She worked at the clinic as a full-time medical assistant from 1982 until she married Gosnell in 1990.

1992– *The Pennsylvania Department of Health Site reviews in 1992 and 1993 also noted various violations, but again failed to ensure they were corrected.

*That leaves the government employees whose job was to make sure that things like this don’t happen. Worth special mention is Janice Staloski of the Pennsylvania Department of Health, who personally participated in the 1992 site visit, but decided to let Gosnell slide on the violations that were already evident then. She eventually rose to
become director of the division that was supposed to regulate abortion providers, but never looked at Gosnell despite specific complaints from lawyers, a doctor, and a medical
examiner. After she was nonetheless promoted, her successor as division director, Cynthia Boyne, failed to order an investigation of the clinic even when Karnamaya
Mongar died there.

1993– Sometime after 1993, the department of health instituted a policy of inspecting abortion clinics only when there was a complaint, but the grand jury found that it didn’t even do that.

1993 – *As far back as 1989, and again in 1993, the Pennsylvania Department of Health cited him for not having any nurses in the recovery room. Gosnell ignored the warnings and the law. He just paid his fines and knowingly continued the dangerous practice of employing unqualified personnel to administer dangerous drugs. It was his modus operandi.

1993– *Maddline Joe worked for 17 years as the receptionist at Women’s Medical Society. In 2007, she became the office manager. She was responsible for payroll,
insurance forms, and filing the reports on all abortions that were mandated by the Abortion Control Act.

1993– *The Pennsylvania Department of Health Site reviews in 1992 and 1993 also noted various violations, but again failed to ensure they were corrected.

1993– After Gov. Tom Ridge, who supports abortion rights, was elected, the state Department of Health stopped inspecting abortion clinics. “Officials concluded that inspections would be ‘putting a barrier up to women’ seeking abortions” and decided “to leave clinics to do as they pleased,” states the report. That practice continued under Gov. Mark Schweiker and Gov. Ed Rendell. It was not until after a drug raid in February 2010 at Gosnell’s clinic that the Health Department resumed regular abortion clinic inspections, according to The Associated Press. Since then 14 of the state’s 22 freestanding abortion clinics have been ordered to remedy problems…

*After 1993, even that pro forma effort came to an end. Not because of administrative ennui, although there had been plenty. Instead, the Pennsylvania
Department of Health abruptly decided, for political reasons, to stop inspecting abortion clinics at all. The politics in question were not anti-abortion, but pro. With the change of administration from Governor Casey to Governor Ridge, officials concluded that inspections would be “putting a barrier up to women” seeking abortions. Better to leave clinics to do as they pleased, even though, as Gosnell proved, that meant both women and babies would pay.

1996– *In 1996, he was censured and fined in two states – Pennsylvania and New York – for employing unlicensed personnel in violation of laws regulating the practice of medicine

1996-Another patient, a 19-year-old, had to have a hysterectomy after Gosnell left her sitting in his recovery room for over four hours after perforating her uterus. Gosnell finished performing the abortion at 8:45 p.m. on April 16, 1996

1998-FIFTEEN-YEAR-OLD Robyn Reid didn’t want an abortion. But when her grandmother forcibly took her to an abortion clinic one wintry day in 1998, Reid figured she’d just tell the doctor her wishes and then sneak away.

1999-Gosnell should have sent another patient, Marie Smith, to the hospital when he was unable to remove the entire fetus during her abortion in November 1999

2000– Latosha Lewis began work at the clinic in 2000, Latosha Lewis worked at the clinic for approximately eight years, beginning in 2000 and ending on February 18, 2010

Gosnell Eileen Oneilljpg
2000– Eileen O’Neill relinquished her Louisiana medical license in 2000 – she claimed because of “post traumatic stress syndrome” – and has not been licensed to practice medicine in any capacity since 2001

SafeandLegal 40yearsabnotsafe

MARCH 2000 SEMIKA SHAW DIES – One involved the 2000 death of Semika Shaw, 22, who died at HUP after getting an abortion at Gosnell’s clinic on Lancaster Avenue and 38th Street. Semika Shirelle Shaw, 22, went to Gosnell’s West Philadelphia clinic for an abortion on March 1, 2000. The next day she called the clinic complaining of heavy bleeding. She died March 4 of a perforated uterus and a bloodstream infection. The suit filed on behalf of her two children alleged that Gosnell failed to tell her to return to the clinic or seek emergency medical care.

2001 Nicole Gaither got an abortion from Gosnell in 2001.

2001– Davida Johnson changed her mind about aborting her 6-month fetus after seeing Gosnell’s dazed, bloodied patients in his recovery room, she said.

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FEB 2001– Tina Baldwin worked at the clinic for nine years, beginning in February 2001 and continuing until the practice closed in February 2010

2001– One of the few former employees who filed a detailed complaint, in 2001 with the Pennsylvania Department of State, got nowhere -which was typical.

*Almost a decade ago, a former employee of Gosnell presented the Board of Medicine with a complaint that laid out the whole scope of his operation: the unclean, unsterile
conditions; the unlicensed workers; the unsupervised sedation; the underage abortion patients; even the over-prescribing of pain pills with high resale value on the street. Department assigned an investigator, whose investigation consisted primarily of an offsite interview with Gosnell. The investigator never inspected the facility, questioned other employees, or reviewed any records. Department attorneys chose to accept this incomplete investigation, and dismissed the complaint as unconfirmed. Shortly thereafter the department received an even more disturbing report – about a woman, years before Karnamaya Mongar, who died of sepsis after Gosnell perforated her uterus. The woman was 22 years old. A civil suit against Gosnell was settled for almost a million dollars, and the insurance company forwarded the information to the department. That report should have been all the confirmation needed for the complaint from the former employee that was already in the department’s possession. Instead, the department attorneys dismissed this complaint too. They concluded that death was just an “inherent” risk, not something that should jeopardize a doctor’s medical license.

2002– Marcella Stanley Choung Quits *Gosnell’s practice of having unqualified personnel administer anesthesia began years before the death of Mrs. Mongar. We heard from a former employee, Marcella Stanley Choung, who told us that her “training” for anesthesia consisted of a 15-minute description by Gosnell and reading a chart he had posted in a cabinet. She was so uncomfortable medicating patients, she said, that she “didn’t sleep at night.” She knew that if she made even a small error, “I can kill this lady, and I’m not jail material.”

*One night in 2002, when she found herself alone with 15 patients, she refused Gosnell’s directives to medicate them. She made an excuse, went to her car, and drove away, never
to return. Choung immediately filed a complaint with the Department of State, but the department never acted on it. She later told Sherilyn Gillespie, a Department of State
investigator who participated in the February raid, that she has worked at seven different abortion clinics and “she has never experienced an illegally run, unsanitary, and unethical facility such as the Women’s Medical Society operated by Dr. Gosnell.” She has never reported any other provider or facility to state authorities.
State Department prosecuting attorney Mark Greenwald and his supervisor, Charles J. Hartwell, closed an investigation involved a complaint brought by a former Gosnell employee, Marcella Stanley Choung, who told the State Department in 2001 and 2002 that Gosnell was using unlicensed workers to administer anesthesia to patients and said she thought a second-trimester patient died at a hospital after Gosnell performed an abortion.

2002- 2009– Between 2002 and 2009, the grand jury learned, attorneys for the state’s medical licensing board reviewed five cases against Gosnell. They closed three without investigation. The last two were investigated and closed without action -including the death of a 22-year-old whose family sued Gosnell and received a $400,000 settlement. (3) Between 2002 and 2009, Board of Medicine attorneys reviewed five cases involving malpractice and other complaints against Gosnell. (The Grand Jury also received records of three older complaints – from 1983, 1990, and 1992 – one of which resulted in a reprimand.) None of the assigned attorneys, or their supervisors, suggested that the Board take action against the deviant doctor. In fact, despite serious allegations, three of the cases were closed without any investigation. The other two were investigated and then closed – without any action being taken.

2002– 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.

*In all this inaction, one failure to investigate stands out. On October 9, 2002, the Professional Underwriters Liability Insurance Company reported to the State Board of
Medicine that it had paid a $400,000 settlement to the family of Semika Shaw, the 22- year-old mother of two who died following an abortion procedure at Gosnell’s clinic in
March 2000. (In January 2003, the Pennsylvania Medical Professional Liability Catastrophe Loss Fund reported to the Department of State that it had paid an additional
$500,000 toward a $900,000 award to the family.) The October 9 report is logged in as “received” by the Department of State’s “Complaints Office” on December 6, 2002. The
file turned over to the Grand Jury shows no further activity until over a year later – January 2, 2004 – when a one-page printout of Gosnell’s license information is stamped
“received” by the complaints office.
Gosnell freezer-gal

2003– Years earlier, in August 2003, another branch of the city’s health department had received an anonymous complaint about Women’s Medical Society. Mandi Davis, a sanitation specialist in the environmental engineering section, wrote a memo to a colleague at the department, Ken Gruen, with a copy to then-Assistant Health
Commissioner Izzat Melhem. She informed them that she had received a “rather disturbing” complaint of aborted fetuses stored in paper bags in an employee refrigerator
at Gosnell’s clinic. Davis requested that a site visit be conducted to assure that proper infectiouswaste handling and disposal practices were in place. Davis further instructed Gruen: “I am not expecting a ‘wild goose chase’ for aborted fetuses.” Current Philadelphia Health Commissioner Donald Schwarz testified that notations on the memo seem to indicate that a site visit was, in fact, made. The city health department, however, could not produce any report of that site visit. Nor is there evidence that the department took any action against Gosnell for his dangerous handling of medical waste, or for his failure to have an approved infectious waste plan, as is required by the city Health Code.

MASSOF
2003 Steven Massof began working at the clinic in July 2003 and left in June 2008

2004-State Department prosecuting attorney Mark Greenwald and his supervisor, Charles J. Hartwell, in 2004 decided to close two investigations into Gosnell. One involved the 2000 death of Semika Shaw, 22, who died at HUP after getting an abortion at Gosnell’s clinic on Lancaster Avenue and 38th Street.

Gosnell biohazard-bags-gal
2004– On May 7, 2004, a city health department inspector was sent to the clinic. His report stated that proper labels were missing from areas where waste was stored; that red bag containers for infectious waste were not lidded; that marked boxes of infectious waste were sitting on the basement floor – not raised as they should be; that red bags for pick-up were not properly stored in the basement; and that 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.

2004– State Department prosecuting attorney Mark Greenwald and his supervisor, Charles J. Hartwell, in 2004 decided to close two investigations into Gosnell. One involved the 2000 death of Semika Shaw, 22, who died at HUP after getting an abortion at Gosnell’s clinic on Lancaster Avenue and 38th Street. The other investigation involved a complaint brought by a former Gosnell employee, Marcella Stanley Choung, who told the State Department in 2001 and 2002 that Gosnell was using unlicensed workers to administer anesthesia to patients and said she thought a second-trimester patient died at a hospital after Gosnell performed an abortion. *Attorneys for Pennsylvania’s Department of State disregarded notices that numerous patients of Gosnell were hospitalized – infected, with fetal remains still inside them; and with perforated uteruses, cervixes, and bowels. Incredibly, in 2004, Department of State attorneys closed – without investigation – a case reported to the Board involving the death of 22-year-old Semika Shaw.

SEPT 2005– “In September 2005, a plaintiff’s attorney sent a copy of a malpractice complaint he had filed against [abortionist Kermit] Gosnell to the Department of State. The case involved a patient we will call “Alice.” She had suffered a seizure after Gosnell administered anesthesia to her in a procedure room as he prepared to perform an abortion in March 2005. Alice had notified clinic staff that she was undergoing methadone treatment and that she had received her daily methadone dose before the procedure. The lawsuit alleged that, despite this warning, Gosnell gave her a medication that was clearly contraindicated for people on methadone, triggering a seizure. According to the complaint, Alice told Gosnell to stop the medication when she started to have a reaction, but Gosnell ignored her and continued the IV injection. Alice began to convulse and fell off of the procedure table, striking her head. A companion who had accompanied Alice to the clinic was summoned to the procedure room to assist. He found the patient naked and convulsing on the floor and asked that someone call 911. When Gosnell denied his request, the companion attempted to leave the clinic to summon help. The complaint alleges that the doors were locked and the staff refused to let him out. As a result, Alice convulsed for an hour while Gosnell and the staff refused to allow her companion to leave the clinic to get help. Finally, Gosnell permitted the companion to go get some methadone to administer. The additional methadone stopped the convulsions- On May 4, 2006, David Grubb, another prosecuting attorney for the Board of Medicine, recommended closing the file without any investigation or prosecution. On June 9, 2006, Grubb wrote to Gosnell informing him that the Department of State had decided that no further investigation was warranted.

2006-When Gosnell applied to renew his medical license in December 2008, he indicated, as he was required to, that a civil malpractice lawsuit had been filed against him in November 2008. He had not sent a copy of the complaint to the Board of Medicine, as required by MCARE, but he eventually did so after it was requested.
The lawsuit was brought by Dana Haynes, who had gone to Gosnell for an abortion on November 11, 2006.

MAY 2006 – On May 4, 2006, David Grubb, another prosecuting attorney for the Board of Medicine, recommended closing the file o Alice without any investigation or prosecution. ( See Sept 2005) On June 9, 2006, Grubb wrote to Gosnell informing him that the Department of
State had decided that no further investigation was warranted.

JUNE 2006 – (CASE of ALICE see Sept 2005) On June 9, 2006, Grubb wrote to Gosnell informing him that the Department of State had decided that no further investigation was warranted.

AUGUST 2005– On August 2, 2005, a “Compliance Coordinator” for the MCARE Fund had notified the Department of State that Gosnell was not in compliance with the MCARE law’s requirement that doctors carry liability insurance. On September 28, 2005, and again on July 5, 2006, Prosecuting Attorney Newport wrote to Gosnell, requesting that the doctor respond to the complaint that he was non-compliant with MCARE’s liability insurance requirements. On July 20, 2006, Gosnell’s insurance agent sent a response to a Department of State paralegal, asserting that Gosnell was covered from 1998 through 2003. For the next two years, the paralegal, at Newport’s request, kept checking with various compliance officers at the MCARE Fund to ascertain whether Gosnell was compliant. The answer was always no. Nevertheless, on September 5, 2008, the paralegal followed Newport’s
instructions and recommended closing the file. The file was closed without any meaningful investigation.

September 2005– a plaintiff’s attorney sent a copy of a malpractice complaint he had filed against Gosnell to the Department of State. The case involved a patient we will call “Alice.”

2005: Kareema Cross worked at the clinic for four and a half years, beginning in August 2005

2006– After ripping Dana Haynes’ cervix, uterus and bowel during a botched abortion, Kermit Gosnell – the West Philadelphia doctor now charged with murder – kept her bleeding and writhing in pain for four hours without calling for help, city prosecutors contend. The doctor called an ambulance only after Haynes’ cousins yelled to be let into his Women’s Medical Society clinic and ordered him to do so. At the Hospital of the University of Pennsylvania, doctors found that most of the nearly 17-week fetus still remained in Haynes’ uterus. She needed extensive surgery and stayed at HUP for five days. Haynes’ November 2006 case represents just one of many examples in which authorities – particularly state officials – failed to investigate alarm bells that warned something awful was happening at Gosnell’s clinic, according to the 261-page grand-jury report released by the District Attorney’s Office on Wednesday.
http://articles.philly.com/2011-01-21/news/27040987_1_abortion-clinics-grand-jury-report-uterus

2006-The grand jury found that HUP had, as required by state law, reported to authorities information about Shaw’s death in 2000, but said it found that no reports were made when Mongar died at HUP in 2009 or after Haynes went there in 2006.

2006-*In September 2006, Gosnell hired Ashley Baldwin, Tina’s daughter, to work at his clinic when she was just 15 years old. She was a sophomore in high school. She came to the clinic each day in the early afternoon. In the beginning, her job was to answer phones and do paperwork. But before the end of her sophomore year, Gosnell assigned
her to attend to the abortion patients in the recovery room.

2007– RETIRES *Anna Keith was Gosnell’s aunt. She was the office manager until she retired in 2007.

2007– *Maddline Joe worked for 17 years as the receptionist at Women’s Medical Society. In 2007, she became the office manager. She was responsible for payroll,
insurance forms, and filing the reports on all abortions that were mandated by the Abortion Control Act.

2008– Shayquana Abrams, 21, of Chester, who testified that her health collapsed days after undergoing an abortion from Gosnell in 2008
GosnellSherryWEST

2008– Sherry West was hired by Gosnell in October 2008

2008– Lynda Williams was hired to work full-time in 2008

2008— – unlicensed worker, Steve Massof, left and Tina Baldwin and Latosha Lewis stopped working nights

2008– Massof began working at the clinic in July 2003 and left in June 2008

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.

2008– By 2008, as the number of women and girls seeking first-trimester abortions from Gosnell shrank

Gosnell BABY A
2008 – Baby A” – was born in July 2008 so large and seemingly healthy in the 29th week of pregnancy

2008-When Gosnell applied to renew his medical license in December 2008, he indicated, as he was required to, that a civil malpractice lawsuit had been filed against him in November 2008. He had not sent a copy of the complaint to the Board of Medicine, as required by MCARE, but he eventually did so after it was requested.
The lawsuit was brought by Dana Haynes, who had gone to Gosnell for an abortion on November 11, 2006.

2008-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.

2009– Kareema Cross stopped assisting Gosnell with procedures in July 2009.

ms-Mongar

2009 – NAF Gosnell submitted an application to become a NAF member in November 2009 – apparently, and astonishingly, the day after Karnamaya Mongar died

2009-On October 7, 2009, Matijkiw returned to the clinic. Again she wrote a scathing report, addressed, again, to her supervisor, Lisa Morgan. In it Matijkiw described a two hour meeting with “(Dr.) O’Neill” (the parentheses were in her original email). During the visit, Matijkiw learned that O’Neill had no understanding of the vaccine program. O’Neill reportedly believed that the free children’s vaccines could be given to adult patients and to those with private insurance. Matijkiw noticed that one of the free vaccines was given to Gosnell’s daughter. A month after Matijkiw’s second visit to the clinic, Mrs. Mongar died. A month after that, in December 2009, a notation in Philadelphia Department of Public Health records stated: “Site will not be enrolled in [the Vaccine for Children program] after Matijkiw’s visits. We will pick up any wasted vaccines in January. Jim is reporting Dr. to state licensing.”

2009-The grand jury found that HUP had, as required by state law, reported to authorities information about Shaw’s death in 2000, but said it found that no reports were made when Mongar died at HUP in 2009 or after Haynes went there in 2006.

2009– 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.

2009– The investigators also learned that in November 2009 an abortion patient had died. That prompted state authorities to yank Dr. Gosnell’s medical license and shut down the clinic.

2009– *Randy Hutchins was the only licensed medical provider, other than Gosnell, to work with any regularity at the clinic in the last several years. However, it was not lawful for him to perform the duties assigned by Gosnell because Gosnell did not obtain the State Board of Medicine’s approval, as required. Hutchins testified that he worked for Gosnell for a year in the 1980s but left after he stole money from the doctor. Hutchins explained that he had a cocaine problem at the time. He returned to work at the clinic in July 2009 partially because Gosnell was willing to allow him to work off the debt. From August until the middle of September, Hutchins said, “I really didn’t get paid.”
Hutchins normally worked Mondays, Tuesday, and Fridays. His primary job was to see “pain management” patients. However, his name also appeared on Karnamaya Mongar’s records on Wednesday, November 18, 2009. Her chart shows that Hutchins inserted laminaria the night before her procedure. Hutchins quit in February 2010, before the raid, because Gosnell never filed the paperwork required to allow him to work legally.

2009– Juan Ruiz, a prosecuting attorney at the State Department – whose Board of Medicine licenses physicians – who in 2009 decided an investigation into Haynes’ case was not warranted after he learned of a lawsuit filed by her. He did not even look at Gosnell’s history or talk to Haynes, according to the grand-jury report.

2009– supervisor Lisa Morgan and medical director Dr. Barbara Watson at the city Public Health Department failed to alert the State Department of abysmal conditions at Gosnell’s clinic reported to them by a nurse who visited the clinic in 2008 and 2009 as part of a vaccine program.

*During the drug-trafficking investigation, District Attorney’s Detective James Wood learned from one of the clinic employees that a woman had died in November 2009, following an abortion procedure. Detective Wood discovered other disturbing details about Gosnell’s medical practice. The premises were dirty and unsanitary. Gosnell routinely relied on unlicensed and untrained staff to treat patients, conduct medical tests, and administer medications without supervision. Even more alarmingly, Gosnell instructed unlicensed workers to sedate patients with dangerous drugs in his absence. Based on this information, Detective Wood believed that further investigation of the woman’s death the previous November was warranted. The detective searched for a police report on the incident, but finding none, he went to the Philadelphia Medical Examiner’s Office to try to identify the woman and to find out more about her death. Detective Wood learned that the dead woman was Karnamaya Mongar, and that her toxicology report revealed an extremely high level of Demerol, a drug Gosnell used at the clinic to anesthetize patients.

JAN 2010- Based on her observations, the evaluator determined that there were far too many deficiencies at the clinic and in how it operated to even consider admitting Gosnell to NAF membership. On January 4, 2010, she wrote to Gosnell informing him of NAF’s decision and outlining the areas in which his clinic was not in compliance

FEB 18, 2010– Latosha Lewis END EMPLOYMENT: began work at the clinic in 2000, Latosha Lewis worked at the clinic for approximately eight years, beginning in 2000 and ending on February 18, 2010

FEB 2010– Federal drug agents raided his clinic, now at 38th Street and Lancaster Avenue, on Feb. 18-That raid triggered another inspection by health investigators four days later. They found his clinic was filthy, with fetal remains filling a freezer and clogging drains. He allowed unlicensed employees to give anesthesia, often leaving patients unattended, the report said. FEB – 2010-The investigation began last February, after federal and state drug agents and Philadelphia police raided the clinic at 3801 Lancaster Ave. on suspicion that Dr. Gosnell was illegally dispensing narcotic painkillers. (A federal drug-trafficking investigation is continuing.)

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FEB 2010– STATE INSPECTORS – *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.”

February 18 raid – RAID

February 22, 2010, the Pennsylvania Board of Medicine suspended Gosnell’s medical license, citing “an immediate and clear danger to the public health and safety.”

March 12, 2010 the state Department of Health filed papers to begin the process of shutting down the clinic.

MAY 4, 2010 The Philadelphia District Attorney submitted this case, pertaining to criminal wrongdoing at Gosnell’s clinic, to the Grand Jury on May 4, 2010

JAN 2011 – arraigned- eight charges of homicide for killing seven newborns and one female patient

JAN 2011 – Less than two days after he was sworn in, Gov. Tom Corbett tasked his secretary of health and commonwealth nominees with finding out “where the breakdowns were” that permitted a West Philadelphia doctor now charged with murdering newborns to operate an abortion clinic described in a grand jury report as a “house of horrors.” Spokesman Kevin Harley said Mr. Corbett read the report Wednesday evening and held a meeting Thursday morning in which he directed Eli Avila, nominee for the secretary ofhealth, and Carol Aichele, nominee for secretary ofthe commonwealth, “to use the grand jury report … to conduct a complete review of each of the agencies to figure out what went wrong,” Mr. Harley said.

FEB 2011- The state Board of Medicine suspended Gosnell’s medical license Monday following a raid of the clinic at 3801 Lancaster Ave. by federal and and state drug agents looking for evidence of illegal distribution of prescription painkillers. http://ht.ly/k7maH

3 Responses to “Gosnell Timeline – what took the state so long to inspect this house of horrors?”

  1. […] Remember Kermit Gosnell – the state failed to inspect his abortion clinic as well – see the timeline here ! […]

  2. […] sounds eerily similar to what took place in Pennsylvania when Kermit Gosnell’s House of Horrors abortion clinic was allowed to operate without any state inspections for […]

  3. […] like with Gosnell – years of practicing and doing illegal activities, the truth finally came […]

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