Dr. Kermit Gosnell and the Philadelphia Abortion Mill

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.