Among the many questions raised by the grisly charges against West Philadelphia abortion doctor Kermit Gosnell, one stands out: How did this go on so long?
Indeed, almost a third of the 260-page report released Wednesday by a Philadelphia grand jury is devoted to that question.
The answer that the jury offers amounts to a scathing denunciation of state regulatory officials and, to a much lesser degree, the city's public health department.
Gosnell, 69, was arrested Wednesday and charged with murder in the deaths of a patient, as well as seven babies born alive and then allegedly killed in the sixth, seventh, and eighth months of pregnancies. Gosnell's wife and eight employees were also arrested, and four of the workers also face murder charges.
The grand jury concluded that, for more than two decades, "government health and licensing officials had received repeated reports about Gosnell's dangerous practices. No action was taken, even after the agencies learned that women had died during routine abortions under Gosnell's care."
Kevin Harley, a spokesman for newly installed Gov. Corbett, said, "The Corbett administration will review the allegations contained in the grand jury's report regarding deficiencies in oversight by both the department of state and the department of health and make it a priority to address those deficiencies."
"This," Harley added, "has to do with enforcing regulations and the law."
Gosnell, who is not trained as an obstetrician-gynecologist, opened his abortion clinic on Lancaster Avenue in 1979, following an on-site review by inspectors from the Pennsylvania Department of Health.
Pennsylvania law requires only an initial inspection of abortion clinics. The frequency of follow-up inspections, the jury was told, has varied from annual to sporadic depending on the abortion stance of the governor.
Other testimony and evidence revealed that:
Gosnell's clinic was reinspected in 1989, 1992, and 1993. Each time, deficiencies were found, including no nurses overseeing the recovery room, missing lab work, no obstetrician-gynecologist on staff, and out-of-date medication. Yet each time, state evaluators reapproved the clinic without requiring or verifying corrective actions.
In early 2002, in response to an inquiry by a lawyer suing Gosnell for malpractice in the death of a patient, a state Health Department official said the agency had received no complaints against the doctor. In fact, it had received four complaints - one hand-delivered by Donald Schwarz, who was then a private-practice pediatrician and is now Philadelphia's health commissioner. Schwarz testified that he stopped referring patients to Gosnell for abortions after he became concerned that they were acquiring a sexually transmitted infection during care at the clinic.
In 2007, the Delaware County Medical Examiner's Office autopsied a stillborn baby, delivered by Gosnell at 30 weeks. The coroner alerted the state Health Department's top attorney about the potential violation of the abortion control law. It bans abortions after 24 weeks unless the woman's life is at risk, among other conditions. Instead of investigating, the agency's attorney said, neither the Health Department nor the medical licensing board had any authority over the matter.
State health officials did not investigate even after learning of the November 2009 death of Karnamaya Mongar, who developed a fatal heart arrhythmia after being overdosed on anesthetics at Gosnell's clinic, according to the jury's report.
The Department of State's Board of Medicine, which licenses medical professionals, also turned blind eyes, the report says. For example, it took no action nine years ago when a former Gosnell employee reported the illegal practice that years later led to Mongar's death: Unlicensed, barely trained workers were anesthetizing patients before he arrived at the clinic.
Board attorneys also "disregarded notices that numerous patients . . . were hospitalized . . . with fetal remains still inside; and with perforated uteruses, cervixes, and bowels."
Some of those reports came from the nearby hospitals where Gosnell's injured patients were rushed.
"Starting in 1999, Penn Medicine provided reports to the authorities regarding patients of Dr. Gosnell who sought additional care at our hospitals," spokeswoman Susan E. Phillips e-mailed Wednesday. "We have cooperated fully with the District Attorney's Office."
Antiabortion groups, which regularly picketed outside Gosnell's clinic over the years, were nonetheless shocked by the charges.
"As bad as the abortion industry is, this is a new low," said Michael J. McMonagle of the Pro-Life Union of Southeastern Pennsylvania.
He said his group would step up efforts to toughen regulation of abortion clinics.
Which is exactly what abortion-rights activists are afraid of.
Dayle Steinberg, president of Planned Parenthood of Southeastern Pennsylvania, said she worried that abortion foes would use this extreme case to taint all providers.
"Abortion is already . . . quite strictly regulated," she said, "and no new regulations can stop a physician who decides to disregard the law."
Philadelphia health officials also "ignored alarming warnings about Gosnell's practice," the jury report concluded.
For example, the city dropped Gosnell's clinic from a child vaccine program in 2009 after a health department nurse repeatedly found that he didn't maintain records and stored vaccine in filthy, unsuitable refrigerators. The city also received complaints - and confirmed them - that Gosnell was violating regulations for disposal of medical waste.
Yet no punitive action was taken, the report says.
On Wednesday, Schwarz, the city health commissioner since January 2008, acknowledged that improvements were needed - although he contended the city's authority in such situations was limited.
The city closed Gosnell down as a child vaccine provider "but didn't report him to the state," Schwarz said. "It raises the question of how the city communicates with the state. We need a better way to help people get complaints about providers to the state."