By many accounts, Kermit Gosnell's abortion clinic has operated for years in ways that raised red flags.
Yet it wasn't until last week that the State Board of Medicine suspended the doctor's medical license and shut down his clinic in West Philadelphia, calling it a "clear danger to the public."
The suspension order - following a raid by federal drug agents who suspect Gosnell was illegally distributing prescription painkillers - cited unsanitary and "deplorable" conditions, including bloody floors and fetuses in jars. It also said an unlicensed worker routinely administered prescription painkillers to patients, including one who developed a fatal heart arrhythmia in November after receiving multiple doses.
Interviews with state officials, former patients, lawyers, doctors, and activists on both sides of the abortion debate reveal that numerous opportunities to shine a light on Gosnell's problematic practice were missed or not pursued.
In 2005 and 2008, for example, Gosnell complied with Pennsylvania law by reporting to the Board of Medicine that was being sued for malpractice. The 2005 case, which alleged a patient suffered a perforated uterus and bowel, was dropped. The 2008 case, which alleged a patient had convulsions after receiving the wrong anesthesia, was settled.
Prosecutors with the state's bureau of professional and occupations affairs reviewed both cases and decided they did not warrant disciplinary action, said bureau commissioner Basil Merenda.
"In my experience, two cases in eight years is not a lot," explained supervising prosecutor Kerry Maloney. "That's not alarming."
The law requiring doctors to report malpractice suits took effect in 2002. Prosecutors could have checked public records of Gosnell's history in prior years.
If they had done so, prosecutors would have seen that Gosnell was named in eight more malpractice suits dating back to 1981, including one that involved a death. The patient died of a perforated uterus and bloodstream infection. The case was settled in 2002 for an undisclosed sum.
Prosecutors would also have noticed that Gosnell paid $10,000 in 2007 to settle a civil lawsuit for performing an abortion on a minor without parental consent. As a violation of the state's abortion control law, this would have triggered a suspension of his medical license pending an investigation.
"We can't prosecute what we don't know," Maloney said.
Gosnell has declined requests for comment.
It can be difficult to tell state authorities about dubious medical practices, say some who have tried.
More than a decade ago, CHOICE, a Philadelphia abortion referral service, contacted the state medical board about Gosnell because some of his patients had called CHOICE with appalling stories, said Brenda Green, the organization's executive director.
"We were told that we could not file a complaint. It had to be a patient. It could not be a third party," Green said.
Reproductive health activists and Gilbert Abramson, a lawyer who filed the 2008 case that was later dropped, said they urged Gosnell's patients to file complaints with the state. But when the women learned that they would have to provide medical records and other forms, plus attend a hearing in Harrisburg, they changed their minds.
"We couldn't get women to do it," said Susan Schewel, executive director of the Women's Medical Fund, which provides financial help to poor women seeking abortions.
Filing a complaint may be particularly daunting for women who are poor and undereducated - as were many of Gosnell's patients. Karnamaya Mongar, 41, the patient who died last fall, had arrived in the U.S. just five months earlier from Bhutan, an impoverished country between China and India, according to her brother Damber Ghalley.
Gosnell's clinic, at 3801 Lancaster Ave., has never been on CHOICE's referral list because it never submitted to an inspection by the organization, Green said. And because the clinic had a bad reputation, the Women's Medical Fund turned away women who planned to go to there, Schewel said.
In Pennsylvania, abortion clinics are automatically inspected by the state Department of Health only when they open or relocate. In New Jersey, in contrast, clinics must be inspected every other year.
Yesterday, State Rep. Matthew Baker (R., Tioga), who sits on the House health and human services committee, said he hopes to change the Pennsylvania law.
"I intend to look into requiring mandated unannounced inspections of all abortion clinics if the Department of Health does not decide to do these on their own," Baker said.
Even though inspections are not regularly carried out, the health department receives quarterly reports from abortion providers. Maternal deaths and any complications, including hemorrhage, infection, uterine perforation, and retained fetal parts, must be included in the reports.
Health department spokeswoman Stacy Kriedeman yesterday said officials could not comment on individual clinics because the information is confidential.
Statewide, she said, the department received only 67 reports of complications in 2008 out of 38,807 abortions, she said.
Two pieces of the quarterly clinic reports are public record: the total number of abortions, and how many were performed in the first and second trimesters.
Most clinics will not do abortions after the first trimester (through to 14 weeks) because the procedure is medically more difficult and time-consuming. Most states, including Pennsylvania, ban abortion after fetal viability - about 24 weeks.
Gosnell has long been willing to perform abortions in the second trimester. In 1972, in what turned out to be a disastrous experiment, he tested an abortion-inducing plastic coil on 15 women in their second trimesters; nine developed severe complications.
Mongar, the patient who died in November, was about 18 or 19 weeks pregnant, according to her brother.
Nonetheless, Gosnell's abortion reports for 2006, 2007, 2008 and the first three quarters of 2009 (before Mongar's abortion) list only one second-trimester procedure, in the second quarter of last year.
Green and other abortion rights activists yesterday held a news conference to decry Gosnell's substandard care - and the lack of Medicaid funding for abortions in Pennsylvania.
"What happened inside that building is not the real story. The real story is why women sought care there at all," Schewel said. "This prohibition on Medicaid payment leaves desperate women vulnerable to substandard providers."
So do missed opportunities for corrective action.
"I have to think this will lead to tighter regulatory oversight, given the number of times this guy has slipped through the cracks," said Melissa Weiler Gerber, executive director of Women's Way, the Philadelphia-based charitable fund-raising network.