The Women's Medical Society

All information in this post is taken from an indictment handed down by the First Judicial District of Pennsylvania. All suspects are innocent until proven guilty in a court of law.

I.

The sad sordid tale of Dr. Kermit Gosnell underscores the abject failure of our Medical-Industrial Complex to purge its ranks of even its worst offenders.

The story of Dr. Gosnell and his abortion clinic, the Women’s Medical Society, told in a 281-page indictment handed down by R. Seth Williams, District Attorney for the First Judicial District of Pennsylvania, reads like a horror novel.

The indictment describes the Women’s Medical Society as a place of squalor, of misery, and of death. A filthy aquarium in the waiting room stank from the crushed clams and baby formula the workers fed to the fish and turtles imprisoned therein. Bags and boxes of medical waste lay piled atop one another for months, their contents leaking out.

The floors, the chairs, and even the stirrups on the procedure table were spattered with dried blood. Bathrooms were cleaned only once a week, even though the patients were vomiting into the toilets and delivering babies into them.

The remains of aborted fetuses were everywhere, stashed in bags, milk jugs, juice cartons, and cat food containers. Fetuses were even stored in the same refrigerator that held the employees’ lunches.

Elsewhere were numerous jars which held just the severed feet of aborted fetuses.

Two flea-bitten cats had the run of the place, shedding hair, vomiting, urinating, and defecating at will. These cats slept in the same beds that held Dr. Gosnell’s patients.

The patients, many of whom had come to Dr. Gosnell seeking second- or even third-trimester abortions, lay unattended for hours, stripped naked below the waist beneath blankets that were washed once a week, in a drugged stupor or moaning in pain.

Two of the individual’s in Dr. Gosnell’s employ, Steven Massof and Eileen O’Neill, had graduated from medical school but were not licensed to practice medicine in any state.

A third, Randy Hutchins, who worked part-time at the clinic, was a licensed physician’s assistant. According to the indictment, he had worked for Dr. Gosnell for a year in the 1980’s but left after he was caught stealing money. Hutchins allegedly explained that he had had a cocaine problem at the time. He returned to Dr. Gosnell’s employ in July 2009, but left in February of the next year. He claimed that his boss never bothered to file the paperwork which would allow him to work there legally.

According to prosecutors, none of the Women’s Medical Society’s other employees had any remotely relevant credentials. Whatever perfunctory training they had, they received either from Dr. Gosnell or each other. Ashley Baldwin, who went to work for Dr. Gosnell at the age of fifteen and became one of the prosecution’s star witnesses, testified that her “training” to administer anaesthesia to patients lasted all of twenty minutes.

The indictment alleges numerous other violations of accepted medical practice, not to mention common sense. Disposable single-use medical devices, such as the plastic curettes used to remove tissue from uteruses, were used again and again until they broke; other medical devices were not sterilized between uses. One clinic worker testified that she saw Dr. Gosnell take a speculum covered with one woman’s blood and insert it into another woman’s vagina. The suction source used to perform abortions was the only one available to resuscitate patients. The source’s vacuum meter was covered with a brown substance, making the numbers barely readable. The oxygen masks and tubing lay covered in a thick layer of dust. The clinic’s only EKG machine and pulse oximeter had not worked in years.

While the Women’s Medical Society opened its doors at noon, Dr. Gosnell usually didn’t come rolling in until eight, nine, or ten PM, or even later. He preferred to spend his afternoons elsewhere, jogging and swimming to keep fit and trim. Allegedly, the clinic workers would administer labor-inducing drugs and then sedate the patients until Dr. Gosnell arrived.

With the possible exceptions of Massof, O'Neill, and Hutchins, none of the workers had any training in administering sedatives, other than the perfunctory “training” provided by the clinic itself. The indictment claims that Dr. Gosnell performed no evaluation of patients before sedatives were prescribed; rather, patients themselves chose from a variety of options, labeled “Local,” “Heavy Sleep,” “Twilight Sleep,” and “Custom Sleep.” No allowances were made for a patient’s weight, age, health, or any other individuals factors that might affect their reaction to sedation. Ashley Baldwin, the high-school student employed by Dr. Gosnell, made up a hand-written color-coded chart listing various drugs and dose levels for each level of sedation -- a sort of "Anaesthesia for Dummies."

Prosecutors claim that even these rudimentary guidelines were routinely ignored by the the staff.

The indictment states that as the women waited for Dr. Gosnell to make his appearance, they were repeatedly drugged by the staff to keep them quiet. For the most part, nobody was keeping track of the kinds and amounts of drugs the patients received, and there was no monitoring of the patients’ vital signs. Most of the time, no licensed medical professional was even on the premises. During Ashley Baldwin’s testimony, when asked who was in charge at the clinic before Dr. Gosnell arrived, she replied “Me.”

Prosecutors claim that Dr. Gosnell’s modus operandi ensured that the many of the heavily pregnant women who made up the bulk of his clientele would give birth prematurely, right there in the clinic. Allegedly, this was by design, as it made Dr. Gosnell’s job that much easier: rather than go through all the work of performing an abortion, all he had to do was to, in his words, “ensure the demise of the fetus.”

In other words, kill the newly-born premature baby.

II.

Pennsylvania law is very clear on this point. The law allows abortion up through the 24th week of pregnancy. Once the baby is out of the mother’s body, if it appears to be viable, the law dictates that resuscitation measures must be carried out. Failure to do so is infanticide. The deliberate killing of a newborn is murder.

The indictment claims that Dr. Gosnell and his staff killed babies that were moving, breathing, and even crying. Steve Massof later testified that any reactions exhibited by any of these newborn babies were dismissed by Dr. Gosnell as “spontaneous movement.”

“That was his answer for if we ever saw anything that was out of the ordinary,” Massof stated. “It was always a spontaneous movement.”

Prosecutors allege that most of these babies were killed by severing the spinal cord with scissors;  occasionally, according to the indictment, their brains were suctioned out of their skulls instead. Tina Baldwin, Ashley’s mother, who also worked at the clinic, testified that Dr. Gosnell once quipped “That’s what you call a chicken with its head cut off” as he cut a baby’s spinal cord.

The District Attorney claimed to have documented the murder of at least seven newborn babies, although the total number was estimated to be in the hundreds. After viewing a cell phone picture taken of one of these babies, known as Baby Boy A, a neonatologist estimated his gestational age at 32 weeks. The indictment states that after severing the baby’s spinal cord, Dr. Gosnell stuffed him into a shoebox. The baby was so big his arms hung out over the sides. As the baby continued writhing, Dr. Gosnell assured his staff, “It’s the baby’s reflexes. It’s not really moving.”

Allegedly, Dr. Gosnell joked that the baby was big enough to “walk me to the bus stop.”

Prosecutors claim that when Dr. Gosnell was not around, his staff took over the job of killing newborn babies. Steve Massof (known to the other employees as “Dr. Steve”) testified that he himself killed as many as 100 newborn infants, some of them already moving and breathing on their own. Ashley Williams testified that “[Dr. Steve] told me that – don’t worry about it. It is just a reaction.”

The indictment states that after Steve Massof left in 2008, clinic worker Lynda Williams took over the job of cutting babies’ spinal cords when Dr. Gosnell wasn’t around.

One such baby, known as “Baby C,” was allowed to live for twenty minutes before it was put to death. Dr. Gosnell delivered the baby and placed it on the counter while he suctioned the placenta out of the mother. Lynda Williams noticed that when she pushed on the baby’s arms, the baby pushed back.

According to the indictment, after playing with the baby, Williams slit its neck.

III.

Prosecutors claim that the women who came to Dr. Gosnell for abortions were harmed in a myriad of ways as well. Many of the women who came to Dr. Gosnell to have their pregnancies terminated became infected with Chlamydia, gonorrhea, or other diseases from the filthy instruments he used. Dr. Gosnell left fetal parts inside women, resulting in severe sepsis. He perforated bowels, cervixes, and uteruses. He left women sterile. At least two women were said to have died as a result of their treatment.

In 2002, 22-year-old Semika Shaw died of sepsis after suffering a perforated cervix and uterus after undergoing an abortion at the Women's Medical Society. Despite a payment to her survivors of almost a million dollars from an insurance carrier and the Commonwealth of Pennsylvania’s Catastrophic Loss Fund – a payment which was duly reported to the Department of State’s Board of Medicine, which licenses physicians – her death failed to set off any alarm bells with authorities.

Likewise, the death of 41-year-old Karnamaya Mongar failed to set off any alarms. Mrs. Mongar was a refugee from the civil war in Bhutan who had spent twenty years in a resettlement camp before being allowed to emigrate to the United States. She spoke no English.

Karnamaya Mongar and her husband

Accompanied by her daughter, Yashoda Gurung, and her mother-in-law, Mrs. Mongar arrived at the clinic at the Women’s Medical Society on 19 November 2009. A family friend, Dhamber Ghalley, drove them, although he chose to wait outside the clinic in his car.

At the front desk, Mrs. Mongar was given a 200 mg. pill of Cytotec (misoprostol) to initiate uterine contractions and a 45 mg pill of Restoril (temazapan), which causes drowsiness. Assigned to attend to Mrs. Mongar in the recovery room were clinic workers Lynda Williams and Sherry West.

That was the first bad sign. Even by the undemanding standards of the Women’s Medical Society, those two were not considered braniacs. More than one co-worker had expressed reservations about Williams, but Dr. Gosnell dismissed such concerns, calling her a “trained professional.”

We don’t know what kind of drugs were given, but it was common for patients at the clinic to be given the “Twilight Dose,” consisting of 75 milligrams of Demerol (meperidine); 12.5 milligrams of promethazine (Phenergan); and 7.5 milligrams of diazepam (Valium). This dose could given repeatedly throughout the afternoon, at the pleasure of the clinic workers. Williams herself claimed that Mrs. Mongar received a “Local” consisting of 10 mg. of Demerol and 12.5 mg. of promethazine. In fact, Ashley Baldwin's handwritten chart described a ”Local” as 10 mg. of a different drug, nalbuphine, and 12.5 mg. of promethazine. Apparently no one, not even the clinic workers themselves, really knew what kind of drugs Mrs. Mongar received, or in what amounts.

All we know for sure is that night Mrs. Mongar received massive doses of Demerol, which caused her death due to respiratory failure.

Shortly before 8:00 PM, Williams and West told Yashoda Gurung that she would have to leave the recovery room. Before she left, Yashoda tried to rouse her mother but was unsuccessful.

Williams and West took Mrs. Mongar to the procedure room, and then called Dr. Gosnell, who allegedly instructed them to “med her up.” Williams later testified that she gave Mrs. Mongar the clinic’s “Custom dose,” which, according to Ashley’s color-coded chart, consisted of 75 mg. of Demerol, 12.5 mg. of promethazine, and 10 mg. of diazepam.

Shortly after that, West emerged from the procedure room, shouting for help. Eileen O’Neill would later testify that Williams came to her office to get her. When she entered the procedure room, Dr. Gosnell was attempting to perform CPR on the Mrs. Mongar. O’Neill was sure that the patient was already dead, but nevertheless she took over the job of performing CPR, believing that Dr. Gosnell was doing it incorrectly. Dr. Gosnell went upstairs to the third floor to retrieve the clinic’s only “crash cart,” which contained the drugs and devices used to treat cardiac arrest. O’Neill said she tried using the defibrillator paddles on Mrs. Mongar, but they didn’t work.

Still no one called 911.

O’Neill would later testify that Dr. Gosnell instructed her not to inject Mrs. Mongar with Narcan – a drug which, according to toxicology experts, can reverse the effects of Demerol. She also claimed that the Gosnell busied himself with checking the expiration dates on the drugs contained on the crash cart and was “overjoyed” to find they were up-to-date, although he made no effort actually to use the drugs to try to revive his patient. Gosnell instructed O’Neill to plug in the pulse oximeter. When she attempted to do so, she got an electric shock.

It wasn’t until after 11 PM that Ashley Baldwin called 911. An ambulance arrived within two minutes.

The paramedics began giving Mrs. Mongar oxygen and inserted an IV line to administer emergency medicines. They also connected her to a heart monitor. They were surprised to learn that, in a clinic of all places, these basic steps had not already been taken. They administered epinephrine and atropine in order to re-start her heart, and finally with the aid of a defibrillator they had brought were able to restore a weak heartbeat.

When the rescuers attempted to transport Mrs. Gosnell to the waiting ambulance, they discovered that the clinic’s emergency exits were locked. No one, not even Dr. Gosnell, knew where the key were. Fireman had to cut through the lock with bolt cutters. More precious minutes were wasted as rescuers tried to maneuver the patient through cluttered hallways that could not accommodate a stretcher.

When Mrs. Mongar arrived at the Hospital of the University of Pennsylvania, she had no heartbeat, no blood pressure, and was not breathing. After 45 minutes of aggressive resuscitation efforts, a weak heartbeat was restored, but Mrs. Mongar never again displayed any observable signs of consciousness. Her condition was deemed hopeless, but she remained on life support until family members were able to arrive from Virginia to say goodbye. At 6:15 PM on 20 November, 2009, Karnamaya Mongar was pronounced dead. Later, the Medical Examiner’s toxicology report showed that, 18 hours after paramedics arrived at the Women’s Medical Society (after which no Demerol had been given) she had a concentration of Demerol in her blood of 700 μg/L.

While the family was waiting at the hospital, Dr. Gosnell arrived to pick up Sherry West. He encountered the Mongar family’s friend Dhamber Ghalley in the parking lot.

Dr. Gosnell told him, “Don’t blame me.”

IV.

The more lurid details of Dr. Gosnell’s practice have already received ample publicity. Less well-known is the story of how officialdom ducked chance after chance to put a stop to it.

The Pennsylvania Department of Health dropped the ball. The Department is charged with writing and enforcing regulations to protect the safety of patients at health care facilities. The Department’s own regulations require it to conduct annual inspections of ambulatory surgical facilities, such as abortion clinics.

The Women’s Medical Society opened for business on 20 December, 1979. Its certificate expired on 20 December, 1980, but the first documented DOH inspection did not take place until August 1989. Additional inspections were carried out in 1992 and 1993. Each time numerous violations of DOH regulations were recorded, and yet each time the clinic’s license was renewed, after promises from Dr. Gosnell to correct any deficiencies. Important parts of inspection reports were often left blank, such as the sections regarding patient anaesthesia and post-operative care. Inspectors did note that the facility was accessible to for stretchers and wheelchairs, even though the building was multi-level and there were no elevators.

After 1993, even these perfunctory, pro forma efforts came to an end. For a period of over 16 years, the DOH carried out no inspections of the Women’s Medical Society. DOH witness testified that after Tom Ridge became Governor of Pennsylvania, the Department instituted a policy of carrying out inspections of abortion clinics only in response to complaints. In fact, in the years between 1993 and 2010, the Department received numerous complaints about the Women’s Medical Society; it just failed to act on them.

In 1996, one of Dr. Gosnell’s patients suffered a perforated uterus and had to have a radical hysterectomy. Her attorney contacted the Department of Health. The Home Health Director discussed the matter with the DOH Senior Counsel, but no action was taken.

Around that time, Dr. Donald Schwarz, a respected pediatrician who is now Philadelphia’s Health Commissioner, hand-delivered a complaint to the Department of Health that numerous patients of his were coming down with trichomoniasis (a disease which normally is sexually-transmitted) after undergoing abortions at Dr. Gosnell’s clinic. He never heard back from the Department, and no action was taken.

In 2002, an attorney for the family of Semika Shaw contacted the Department of Health regarding Ms. Shaw’s death from sepsis after undergoing an abortion at the Women’s Medical Society. No action was taken.

In November 2009, Dr. Gosnell himself sent the Department of Health a fax informing them of the death of Karnamaya Mongar after she visited the Women's Medical Society. No action was taken.

The Pennsylvania Department of State dropped the ball. The Department’s Board of Medicine is responsible for licensing of individual physicians.

In 2001, the Department received a detailed written complaint from Marcella Stanley Chuong, who had been employed briefly at the Women’s Medical Society. Chuong claimed that her “training” to administer anaesthesia consisted of a fifteen-minute talk by Dr. Gosnell and a look at Ashley Williams color-coded chart. She further alleged that one night she was left alone with 15 patients she had been ordered to medicate. Instead she walked out and never went back.

Chuong proceeded to file a complaint with the Department of State which detailed the whole scope of Dr. Gosnell’s criminal enterprise: the omnipresent filth; the two sick, flea-bitten cats wandering about, vomiting wherever they pleased; Dr. Gosnell’s habit of eating in the procedure rooms; the use of unsterilized instruments, including the re-use of single use curettes; and the use of untrained personnel to administer IV anaesthesia in Dr. Gosnell’s absence.

The Department of State assigned an investigator to the case, whose “investigation” consisted largely of a single off-site interview with Dr. Gosnell; he did not bother to subpoena patient files, interview clinic staff, or even visit the clinic. Even on the basis of this perfunctory investigation, he did recommend action, of a sort; he recommended notifying the Department of Health of numerous violations. Yet even this shirking of responsibility, this fobbing off the matter onto another department, never took place. On April 29, 2004, a Department of State prosecuting attorney Mark Greenwald closed the case. This decision was approved by his boss, the Senior Prosecutor in Charge. No action was taken.

Incredibly, the same prosecuting attorney, on the same day, also closed the case of Semika Shaw, the young woman who suffered a perforated cervix and uterus and died as a result of Dr. Gosnell’s ministrations, without bothering to conduct an investigation – and this in the face of a $900,000 award made to her family, more than half from the Commonwealth’s Catastrophic Loss Fund. Again, this decision was approved by the Senior Prosecutor in Charge. No action was taken.

In September 2005, a plaintiff’s attorney sent to the Department of State a copy of a malpractice complaint he had filed against Dr. Gosnell. The suit was filed on behalf of a woman who had come to the Women’s Medical Society seeking an abortion. According to the complaint, the woman told Dr. Gosnell that she was taking methadone; despite this, Dr. Gosnell administered a medication that was contraindicated for patients taking that drug. The woman suffered a seizure and fell and hit her head. The woman’s companion came into the procedure room and found her lying naked and convulsing on the floor. He claimed that Dr. Gosnell refused either to summon help or to call 911 or allow him to leave the facility to do so. Finally, Dr. Gosnell relented and allowed the man to leave and get some methadone, which stopped the woman’s convulsions. No investigation of the charges was made. No action was taken.

In November 2008, Dr. Gosnell himself sent the Department of State a copy of a malpractice suit filed against him on behalf of Dana Haynes, a 38-year-old woman who had come to him seeking an abortion. She suffered a perforated cervix, uterus, and bowel at his hands. The complaint alleged that instead of summoning help, Dr. Gosnell kept her at the clinic for four hours after that, trying to repair the damage he had done. When her cousins came to the clinic to retrieve her, they were denied entrance. Only when they threatened to call the police were they allowed in, where they found Ms. Haynes lying on a recliner, naked from the waist down, with no monitoring equipment and no one to watch her. She was completely unresponsive. An ambulance was summoned, and at the Hospital of the University of Pennsylvania it was found that Dr. Gosnell had left most of the fetus inside her. She required numerous transfusions of blood and was hospitalized for five days. On 20 April 2009, a prosecuting attorney for the Department of State, closed the case without making any investigation. No action was taken.

The Philadelphia Department of Public Health dropped the ball. In August 2003, Mandi Davis, an employee of the Department’s Environmental Engineering Section, received an anonymous complaint that aborted fetuses were being stored in the employee refrigerator at the Women’s Medical Society. There is no record of an inspector being sent to check on this disturbing report, but the next year an inspector was dispatched to the clinic and reported that labels were missing from the areas where medical waste was stored; that infectious waste was not stored properly; and that Dr. Gosnell was unable to provide a contract from a disposal company. Eventually, Dr. Gosnell did provide a copy of the contract, but her never submitted his plan for disposal of medical waste, and never paid his fee. No action was taken.

Lori Matijkiw, a registered nurse working for the Department’s Division of Disease Control, visited the clinic on 16 July 2008 to conduct a vaccine inspection. (Under the name “Family Medical Society,” Dr. Gosnell’s enterprise purported to be a purveyor of free vaccines for children, supplied by the city.) She found appalling conditions inside -- the filthy aquariums, the thick layer of dust that coated the floors, the omnipresent stink of urine. Expired vaccines were stored in the same freezer which was also packed with plastic bags stuffed with the bodies of dead fetuses. The floor of the freezer was covered with a layer of frozen red liquid. Temperature logs were not kept up to date. When Ms. Matijkiw asked to see the files showing which vaccines had been administered, the staff told her there were none. She related all this information in an email to her superiors. The Department of Public Health suspended the “Family Medical Society’s” participation in the vaccine program but took no other action.

Incredibly, little over a year later the Department of Public Health considered re-enrolling the clinic in the free vaccine program. Once again Ms. Matijkiw was dispatched to the clinic, and once again she documented in an email to her superiors the appalling conditions she found there. No action was taken.

Dr. Gosnell’s professional colleagues dropped the ball. Pennsylvania law requires that any doctor who treats a woman for complications resulting from an abortion report the matter to the Department of Health. Failure to do so is considered unprofessional conduct which can result in action by the Department of State.

The Grand Jury investigation discovered that at least five women had been treated for complications at either the Hospital of the University of Pennsylvania (HUP) or Presbyterian Hospital, the two closest hospitals to the Women’s Medical Society. These five cases are probably just the tip of the iceberg. And yet, the DOH submitted no complication reports when subpoenaed by the Grand Jury, and attorneys for HUP was could come up with only one (which raises the question of why the DOH did not submit this report when asked). That report was for Semika Shaw, who died at HUP in March 2000. No report was made when Karanmaya Mongar died at the same hospital, at the hands of the same doctor, nine years later.

V. 

Incredibly, Dr. Gosnell was allowed to continue to operate until he attracted the attention of the authorities regarding an entirely separate matter. This was his other alleged business venture, even more profitable than late-term abortions: writing fake prescriptions for Oxycontin and other controlled substances.

The Drug Enforcement Agency, the Philadelphia Police Department, and the Philadelphia District Attorney’s office had been investigating reports of illegal drug trafficking at the Women’s Medical Society for months. In the course of the investigation, Detective James Wood discovered that a woman had died as a result of a botched abortion there, and he heard many other disturbing reports about the place, including the appallingly unsanitary conditions and the use of untrained and unlicensed personnel to administer anaesthesia.

Accordingly, DEA agent Stephen Dougherty invited inspectors from the Department of Health and the Department of State to accompany federal agents and police when they raided the place. The raid was carried out on 18 February, 2010, and the horrifying conditions already described came to light. Within a few days, Dr. Gosnell's license to practice medicine was suspended, and the Women's Medical Society was shut down for good. Under the glare of the media spotlight, the Department of Health and the Department of State finally decided they had all the authority they needed to put Dr. Gosnell out of business after all. That’s what makes their failure to act for so long so reprehensible: all it should have taken was one look around the clinic to realize that something was terribly wrong.

When the Grand Jury investigation began, Department of Health officials lawyered up, hiring a high-priced law firm to represent them at taxpayer expense. In her testimony regarding the Department’s failure to respond effectively to the death of Semika Shaw, DOH Chief Counsel Lisa Dutton was unrepentant.

“People die,” she explained.

Booking photos released by the Philadelphia Police Department via nbcphiladelphia.com

All other photos via the First Judicial District of Pennsylvania