Published 03/15/2012
38th St. and Lancaster Ave. More Photos
For over 30 years, Dr. Kermit Gosnell ran the Women’s Medical Society in Philadelphia. Ostensibly, this was a women’s health clinic, where abortions were performed, but also where women could get check ups and prescriptions.
In a normal clinic, the walls are white, the lights are bright, and everything is sterilized and sparkling clean.
In Dr. Gosnell’s world, the walls, the furniture, the chairs, the hospital beds, were bloodstained. The surgical tools used to operate on women often went uncleaned between patients. Fetal parts were kept in the freezer and in jars that lined the hallways. Medical equipment — tools used for saving lives — were broken and corroded. The office was a dangerous maze of narrow hallways, which made moving women from floor to floor or room to room difficult.
But these unsanitary conditions were only part of the egregious violations that Gosnell and his cast of unsavory characters allegedly performed on a regular basis at this clinic.
The Grand Jury investigation report overseen by District Attorney R. Seth Williams is a mind-boggling 281 pages — enough for a novel.
For several months, according to the Grand Jury report, Gosnell had been carelessly handing out prescriptions for drugs like Oxycontin. This is perhaps the only reason he was caught. The Drug Enforcement Agency (DEA), the Philadelphia Police Department, and the Dangerous Drug-Offender Unit busted into Gosnell’s clinic on February 18, 2010. While their aim was to find evidence supporting their drug-trafficking charges — they instead saw that Gosnell’s clinic had entirely different problems — problems that seemed far more serious.
According to the Grand Jury investigation, the conditions inside were described by the agents as: “filthy,” “deplorable,” “disgusting,” “very unsanitary, very outdated,” and “horrendous.”
“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.”
What investigators learned as they began interrogating the employees and going through the files, is that Dr. Gosnell didn’t run a health clinic — he ran a death clinic.
Dr. Gosnell and several of his employees are charged with killing one adult woman, and seven newborn babies. It is alleged that he and his staff killed babies by severing their spinal cords with scissors after they were born from induced labor. Countless others are alleged to have been delivered into a toilet by the women, and fished out later so as not to clog the pipes.
In the state of Pennsylvania, the cut off date for a late-term abortion is 24 weeks. The gestation period is determined by ultrasound. Women who elected to have a late-term abortion must wait 24 hours before undergoing the procedure; and they must receive counseling about other options.
In Dr. Gosnell’s clinic, ultrasounds were routinely fudged to show that the women were not as far along in their pregnancies. Counseling and 24-hour waiting period were waived in lieu of cold, hard cash.
When he wasn’t killing babies or patients, the Grand Jury report alleged, he was infecting women by not using sterilized tools. He spread venereal disease from patient to patient — oftentimes young women from poor backgrounds and immigrant communities. During his surgical procedures, he would often puncture and perforate women’s wombs. They would later need hysterectomies or further surgery. Often, they would be deprived of being able to have babies. Sometimes, according to the report, he’d leave behind fragments of the fetuses, causing his patients to get infections and nearly die. When they would get so sick that they would need to go to an emergency room, Gosnell and his staff would refuse to let them go. It didn’t matter: the hallways were too narrow to transport patients on a gurney. And the emergency exit was padlocked; the key was hard to find, and the lock harder to open.
The clinic was open for over 30 years; and despite numerous reports and incidents, it had never had a full inspection by the heath authorities in the state. There is a now lawsuit underway brought by the family of one of the victims.
During the day, Gosnell’s clinic was primarily used for seeing patients and prescribing drugs. A pre-signed pad was left at the clinic so that staff — none of whom were licensed doctors and nurses — could write prescriptions at will. According to the Grand Jury report, it is estimated that Gosnell pulled in hundreds of thousands of dollars a year. The Grand Jury report also stated “Gosnell was one of the top three Oxycontin prescribers in the state of Pennsylvania.” He had written so many prescriptions that by 2010, a nearby pharmacist had stopped filling the prescriptions coming from Gosnell’s clinic.
Based on the evidence, the Grand Jury recommended charging Gosnell and part-time employee Steven Massoff with conspiracy to violate the Controlled Substances Act.
The fact that none of the employees on his full time staff were trained medical professionals was the biggest red flag that Gosnell was not operating a normal facility. His staff was entirely untrained and paid nearly minimum wage, often in cash.
Among his employees were Ashley Baldwin, a 15-year old full-time high school student, and her mother, Tina Baldwin, who’d worked for Gosnell for nine years. Also employed by Gosnell were Latosha Lewis, Lynda Williams, and Sherry West. In all cases, the women were overseeing and participating in procedures that were far above their pay grade — which wasn’t much. Lewis was paid $7 an hour — with overtime, but then was “upgraded” to $12 an hour and no overtime. If she worked on a late-term abortion, she could get a bonus of $20. West was paid between $8 to $10 an hour.
Like the others, the high school student was given absurd responsibilities: performing ultrasounds, giving patients drugs, and helping with the surgeries. While Tina Baldwin and Lewis had attended the Thompson Institute and received rudimentary medical training, only Baldwn received a certificate of completion — in 2009, near the end of her tenure. Williams, in helping with procedures, would allegedly deliver babies, born fully alive, and then sever their spinal cords — as she had learned from the doctor. Sherry West, a former patient of Gosnell’s, was diagnosed Hepatitis C and never used gloves or other sanitary precautions when touching patients, administering IVs and drawing blood.
There were others — including Randy Hutchins (the only licensed medical provider briefly on staff,) Maddline Joe, Steve Massof and Eileen O’Neill (medical school graduates who were unlicensed and never entered a residency program,) and Andrea Moton, who “assisted” with surgeries and allegedly killed living babies. Also on staff was Pearl Gosnell, Dr. Gosnell’s wife. She administered drugs and performed medical procedures, but her only license was for Cosmetology.
Even Gosnell himself was not board certified and was not officially an obstetrician or gynecologist.
Despite being in charge of the clinic, Gosnell was almost never on the premises, leaving his untrained, incompetent staff alone. They would only resort to calling him once in a while because, as they told the Grand Jury, he had a temper and didn’t like to be bothered. What was Dr. Gosnell doing while his patients moaned in pain, unmonitored by his minimum-wage staff? Swimming, jogging and relaxing.
Meanwhile, his staff were performing dangerous procedures — using outdated, unsterilized and often broken equipment.
The motive for the madness at the Women’s Medical Society was simple: money. In a normal medical clinic, only a doctor administers drugs; this is especially important during surgical procedures when the patient needs to be under anesthesia. But at Gosnell’s clinic, drug packages were sold to women, often for abortions that in a normal clinic would be done in an hour and not require any major pain medication.
The choices were outlined in a handwritten chart made by Ashley Baldwin, the 15-year-old high school student.
The words “Heavy,” “Twilight,” “Custom” and “Local” were color-coded with yellow, green, and blue dots. The amount of drugs for each was incredibly high by any standard, and included a mixture that often could have dangerous double effects on the central nervous system.
The “recipe” for “Twilight”: 75 milligrams of Demerol (meperidine); 12.5 milligrams of promethazine (Phenergan); and 7.5 milligrams of diazepam (Valium).
They were administered without regard to the height or weight of the woman receiving the treatment, not to mention her prior medical history.
Latosha Lewis told the Grand Jury how the patients were presented with their choice of medicine: “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.”
Again, no qualified anesthesiologist was on staff.
The cost of the medicines were printed on a chart that advised:
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.’
The drugs cost $50 more for heavy sedation; $140 for twilight sedation and $200 for the custom option. The cost of an abortion was rated based on how far along the mother was — if the woman was willing to pay cash and was only four to eight weeks pregnant, the procedure cost $450. But women who were between 21 to 24 weeks pregnant paid between $1575 to $1850 in cash.
For those women who were there for the late term abortions, the procedures were a two-day affair. They would arrive the afternoon or evening prior to the operation, and one of Gosnell’s untrained staff would start inducing labor. Cytotec was given to most of the women to begin contractions. Normally put inside a patient’s lip, Williams habitually put in it inside their vaginas. Sometimes, the staff would sometimes insert synthetic or seaweed rods called laminaria the night before their procedure, to help the dilation of the cervix. This procedure is delicate and should be performed by a doctor. .
Because the cramping from the laminaria and the Cytotec was so severe, the women were often in excruciating pain for hours at a time. Gosnell was usually not on the premises. This meant they were immediately drugged — often to the point of overdosing. Restoril, a sleep disorder treatment with muscle relaxant properties, was the drug of choice — often given in addition to the sedation packages.
Most of the time, eight or ten women were kept in a single room, moaning and groaning in pain. Gosnell’s instructions were to drug them up as much as possible to “quiet them.”
Tina Baldwin testified at the Grand Jury that they would take the loudest woman, “Put her in a room, let’s give her her medication, quiet her up. She’s upsetting everybody else. So usually she would get done first.”
Sometimes, Baldwin testified, Gosnell would slap women to get them to shut up; if that didn’t work, he would completely sedate them. He did this because he was afraid that any screaming would be cause for attention from the police.
Though the amounts given were already careless, a bigger problem was that the staff didn’t keep track of when they had dosed someone, or how much they had already dosed someone. In some cases, they didn’t even follow the dosage as laid on the pre-sale chart. This was especially true of Sherry West and Lynda Williams. According to testimony by another employee, Kareema Cross, Williams routinely used too much medication in her drug dosages, causing Cross to complain about it to Gosnell himself. Gosnell responded by instituting a logbook of drug dosages — but that was only put in place to keep them from spending too much money. They still did not keep track of the drugs on the patient charts.
Even more troubling, the clinic was not outfitted with up-to-date or working monitoring equipment. At hospitals, patients are hooked up to machines that keep track of their heartbeats and their breathing. According to the Grand Jury report, “Without the benefit of machines, monitoring at a minimum would require physically watching the patients to make sure they were breathing. Neither Williams nor West did this.”
This reckless and cavalier attitude towards administering heavy drugs is what ultimately led to the overdose and cardiac arrest of Karnamaya Mongar.
Mongar was a 41-year old Nepalese refugee. She was only 4’11” and 110 pounds. She had a daughter, Yashoda Gurung, and was married. On 2:30, November 19, 2010, she was admitted to the clinic, and immediately dosed with Cytotec and Restoril by Williams and West. Gosnell was not on site, but Gurung clearly thought the two women were doctors, and referred to them as such. They did nothing to dissuade her.
According to the Grand Jury report: “Mrs. Gurung testified that, between 3:30 and 8:00 p.m., her mother was given five or six doses of oral medicine.” The medicine was likely Cytotec. She was then put to sleep for a few hours. They didn’t stay in the room to monitor Mongar. When Mongar’s daughter tried to visit her mother in the recovery room, she found her mother unresponsive — instead of double-checking on her mother’s vital signs, the staff told her that she was sleeping and sent Gurung to another waiting room until the doctor arrived.
Dr. Andrew Herlich, the Chairman of the Anesthesia Department at the University of Pittsburgh Medical Center, testified about the dosages used by Gosnell and his staff as being outrageous. “Mr. Herlich opined that if average-sized adults, with no particular sensitivities to the drugs, were given two ‘custom’ doses within four hours, ‘most would stop breathing.’”
Gosnell had arrived and was attempting to perform CPR; when that failed, they went upstairs to retrieve the “crash cart,” which contained medication that can help revive someone having a heart attack. They attempted to use the defibrillator. But like most of the medical equipment at the facility, it didn’t work.
An ambulance was ultimately called at 11 p.m., three hours after Mongar’s daughter had seen her be unresponsive. Gosnell and his staff omitted key facts: they didn’t tell the EMTs that she had been given Demerol. By the time EMTs arrived, they had removed her IVs. They also hadn’t bothered injecting her with Narcan, which can jump start a failing heart.
At least ten minutes had passed between the administering of CPR and the 911 call; more minutes still passed when the medics couldn’t get into the facility because of the locked emergency exit.
After 45 minutes, Mongar’s heart started beating and she was taken to Intensive Care at the hospital where she was put on life support until her family could arrive. She was pronounced dead the next day.
An 18-page chapter in the Grand Jury report is entitled “The Intentional Killing of Viable Babies.” Gosnell was supposed to perform abortions, but because he often performed abortions on women who were well past the legal limit of 24 weeks, many of the fetuses were fully-formed and could survive if delivered. The practice of inducing labor, actually meant that many of the women gave birth. Sometimes they were told to sit on a toilet and expunge the baby, because Gosnell was not there to oversee the procedure. Other times, a baby would come out of the womb and Gosnell would take a live, screaming, kicking baby and sever its spinal cord with a snip of the scissors. It was a practice, the Grand Jury report alleges, that happened hundreds of times over the years, but because much of the paperwork and evidence was destroyed, there were only seven provable incidents.
His young victims included Baby Boy A, nearly 7 and a half months, killed and discarded in a plastic shoe box. Baby Boy B, 28 weeks, was frozen forever in a gallon water bottle. Baby C was living in the world for 20 minutes before Williams, according to testimony by Cross, came in and extinguished the new life with a slice to the neck, as she’d seen Gosnell do.
Kareema Cross had actually taken a picture of Baby A, because he was so large. At 18 to 19 inches, he was large enough for the doctor to joke about: “This baby is big enough to walk around with me or walk me to the bus stop.”
Cross testified: “I knew something was wrong because everything, like you can see everything, the hair, eyes, everything. And I never seen for any other procedure that he did, I never seen any like that.”
Where were the authorities? Surely a place this disgusting and dangerous would have been noticed and reported. Though many of the women were likely too scared to go to police (they had after all, undergone an illegal procedure), many times they would turn up at hospitals with fetal remains still inside them, bleeding from puncture wounds, or going into septic shock from infection. The doctors who treated these women would sometimes alert authorities, attorneys who were representing some of the women would complain to the Department of Health. The powers that be even knew that a woman had died while at his clinic and had been tipped off by a former employee to the full extent of the conditions there years earlier.
Incredibly, though, no one inspected the premises between 1993 and 2010, and Gosnell stayed in business.
It may have taken 30 years, but the process of justice for the women who went to Gosnell’s clinic is moving swiftly. Mongar’s family is suing the city of Philadelphia over her death; they have also filed a civil suit against Gosnell. Other malpractice suits are under way as well.
Gosnell, his wife, and eight members of his staff have been charged by the city for their actions at the clinic. Most have pleaded guilty to reduced charges. Below is a breakdown of the charges.
Kermit Gosnell, 70, is charged with eight counts of murder — one for Mrs. Mongar and one each for Baby Boy A, Baby Girl A, Baby Boy B, Baby C, Baby D, Baby E, Baby F and Baby G. He is also charged with multiple counts of infanticide, drug delivery resulting in death, conspiracy to commit murder, solicitation to commit murder, abuse of a corpse, racketeering, theft by deception, participating in corrupt organizations, Controlled Substances Act violations, obstruction, tampering with evidence, hindering prosecution, and abortion at 24 or more weeks.
Gosnell’s wife, Pearl Gosnell, was charged with abortion at 24 or more weeks, conspiracy and participating in corrupt organizations. She pleaded guilty on Dec 13, 2011 to performing an abortion after 24 weeks of pregnancy, two counts of conspiracy and participating in a corrupt organization. Her original Feb 15, 2012 sentencing date was deferred to March 21, 2012, when it will again be deferred until Sept. 12, 2012.
Lynda Williams, 42, was charged with murder in the 3rd degree, conspiracy, abortion at 24 or more weeks, participating in corrupt organizations, drug delivery resulting in death and related charges. On November 9, 2011, Williams pleaded guilty to two counts of murder in the 3rd degree, two counts of conspiracy, participating in corrupt organizations and drug delivery resulting in death. Her sentencing is set for March 21, 2012.
Sherry West, 51, was charged with murder in the 3rd degree for the death of Mrs. Mongar, abortion at 24 or more weeks, conspiracy, tampering with records, hindering prosecution, obstructing administration of law and other related offenses. She pleaded guilty on Oct. 27, 2011, to murder in the 3rd degree, conspiracy, drug delivery resulting in death, and participating in corrupt organizations. Her sentencing is set for Sept. 12, 2012.
Adrienne Moton, 33, was charged with murder in the 3rd degree, conspiracy, conspiracy to commit murder and participating in corrupt organizations. She pleaded guilty on Oct 27, 2011, to Murder in 3rd Degree, conspiracy and participating in corrupt organizations. Her original Feb 15, 2012 sentencing date was deferred to March 21, 2012, when it will again be deferred until Sept. 12, 2012.
Dr. Gosnell’s sister-in-law, 51-year-old Elizabeth Hampton was charged with obstructing administration of law, hindering prosecution, perjury, and false swearing. She pleaded guilty on Oct 13, 2011 to perjury. Her sentencing is set for Sept. 12, 2012.
Eileen O’Neill, 54, is a medical school graduate who worked as doctor at the clinic. She had no license or certification. She was charged with theft by deception, conspiracy, perjury, racketeering and false swearing.
Tina Baldwin, 45, was charged with participating in corrupt organizations, conspiracy, and corruption of a minor. According to the DA, she allowed her teenage daughter to administer anesthesia. She pleaded guilty on Nov 14, 2011, to participating in corrupt organization, conspiracy, and corruption of a minor. One conspiracy charge was dropped.
53-year-old Maddline Joe was charged with conspiracy and participating in corrupt organizations. She was the office manager at the clinic. Her trial is scheduled for March 14, 2013. Pre-trial hearings will start August 13, 2012.
An unlicensed medical school graduate, Steven Massoff, 48, was charged with3rd degree murder in deaths of two babies, conspiracy, theft by deception and participating in corrupt organizations. He pleaded guilty on December 13, 2011 to both counts of 3rd degree murder, conspiracy and participating in corrupt organizations.
District Attorney Seth Williams, who oversaw the Grand Jury report, told reporters “I am aware that abortion is a hot-button topic, but as district attorney, my job is to carry out the law. A doctor who knowingly and systematically mistreats female patients, to the point that one of them dies in his so-called care, commits murder under the law.”
Perhaps the good doctor didn’t understand what he was doing was wrong. It seems impossible.
At the time of his arraignment, the AP reported that Gosnell didn’t understand why he was being charged with eight murders. He told a magistrate. “I understand the one count, because a patient died, but I didn’t understand the seven counts.”