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Kermit Gosnell Grand Jury Report: National Abortion Federation deemed Gosnell’s abortion clinic “beyond redemption” but does not tell authorities

by | Apr 1, 2013

By Dave Andrusko

This is a long excerpt from the 261-page Grand Jury report that formed the impetus for abortionist Kermit Gosnell to be charged with eight counts of murder. But it’s important to understand the setting—how even though Gosnell’s Women Medical Society flunked every test the National Abortion Federation required for membership, NAF did not tell authorities.

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Page1re-216x300A national association of abortion providers declined to admit the Women’s Medical Society as a member, finding it to be the worst facility its inspector had ever seen.

Immediately following Karnamaya Mongar’s death in November 2009, Gosnell sought membership in the National Abortion Federation (NAF), a professional association of 400 abortion providers nationwide that offers referrals and services to member providers. Membership is contingent on meeting NAF’s quality assurance standards and is based on an on-site inspection. It is inexplicable that Gosnell believed he could somehow pass such an inspection or meet NAF standards.

A NAF quality assurance evaluator testified before the Grand Jury. She stated that NAF’s mission is to ensure safe, legal, and acceptable abortion care, and to promote health and justice for women. To that end, NAF publishes clinical standards, called Clinical Policy Guidelines that members must follow. These guidelines are drawn from a  review of evidenced-based medical literature and patient outcomes. To be certified by NAF, a provider must submit to an on-site inspection and complete a detailed questionnaire designed to determine whether the provider complies with NAF’s standards. After the initial approval and certification, members must complete questionnaires annually. NAF re-inspects members every five to seven years, or more often if there is a complication or a serious event with a patient.

Gosnell submitted an application to become a NAF member in November 2009 – apparently, and astonishingly, the day after Karnamaya Mongar died. The NAF evaluator conducted a site review on December 14 and 15, 2009. Despite the odd fact that Gosnell’s decision to seek NAF certification coincided with a patient’s death at his clinic, he made no mention of this significant event to the evaluator before she visited. In fact, it was not until their final interview, after she had spent two days with Gosnell at the facility, that he informed her of Mrs. Mongar’s death.

In preparation for NAF’s visit, Latosha Lewis [a Gosnell employee] said that Gosnell and his wife frantically cleaned the facility. The doctor bought new lounge chairs to replace the bloody ones that were there, although by February 18, 2010, they were filthy again. He also re-hired former employee Della Mann, a registered nurse who was a friend of Randy Hutchins and a patient of Eileen O’Neill. Randy Hutchins referred Ms. Mann to Gosnell because the doctor had told Hutchins that he wanted to hire a registered nurse “for a short amount of time.” Mann had worked at the clinic years earlier.

But in fact, Gosnell was not offering Mann a real job – he was paying to use her license for a few days. Gosnell hired Mann, at $31 an hour, to work 6:00 to 9:00 p.m., Mondays and Tuesdays only. He told her that he wanted her to look at charts, evaluate lab work, and initial patient charts as if she – a licensed nurse – had been the person who had taken vital signs and recorded information in the charts.

This short-term job lasted four days and coincided with the NAF site review. Mann said she quit because she was uncomfortable with Gosnell’s fraud, which included paying her with a check, then taking the check back and giving her cash. Gosnell accomplished what he intended: He ostensibly had a licensed registered nurse on his staff – and her license number in his files – during the NAF review.

Despite these efforts, the NAF review did not go well. The first thing the evaluator noted when she arrived at 3801 Lancaster Avenue was the lack of an effective security system. Although the door was locked, when she rang the bell, no one answered. Even though she could not gain entry by ringing, she was able to walk right in when a man exited the clinic. Once inside, she found that the facility was packed with so much “stuff, kind of crowded and piled all over the place,” that she couldn’t find a space to put her small overnight bag. She found the facility’s layout confusing, and was concerned that patients could not find their way around it or out of it. She was also concerned that there were plants everywhere, including in the procedure room and rooms designated as “labs.”

Most alarming was the bed where Gosnell told her out-of-state patients were allowed to spend the night. These patients were unattended and it was difficult to locate the bathroom facilities and the exits. Such a practice does not meet NAF protocols. The NAF evaluator watched a few first-trimester procedures. She noticed that no one was monitoring or taking vital signs of patients who were sedated during procedures. She asked Gosnell about the pulse oximeter that should have been used for monitoring, but he told her it was broken. Apparently, Karnamaya Mongar’s death a month earlier had not caused Gosnell to obtain equipment that worked.

The evaluator did not observe Gosnell’s practice of allowing unlicensed workers to sedate patients when he was not at the facility, as she was there only when Gosnell was there. Such a practice would not comply with NAF standards. The evaluator did note, however, that while she was talking to Gosnell in his office, a patient appeared to have been sedated by one of the staff. Such an action does not comport with NAF standards either. The evaluator cautioned Gosnell that he should make sure he was complying with state requirements because many states – including Pennsylvania – do not allow unlicensed workers to administer IV medications.

The level of medication administered was also troubling to the evaluator. She testified that Gosnell’s own description of the effects of his routine second-trimester dose – that the patient would feel no pain at all – was a description of deep sedation. She added: “that … would really not be a safe situation … for him to be handling himself.” She explained that when deep sedation or general anesthesia is administered, NAF standards not only require that the doctor performing the procedure be present when the anesthesia is administered, they also require that another doctor or an anesthesiologist administer the sedation and monitor the patient. Instead, Gosnell had Lynda Williams, Sherry West, and his other unlicensed workers routinely administer anesthesia without proper supervision or appropriate monitoring of patients.

The evaluator explained to the Grand Jury, as did several medical experts, that because everyone reacts differently to anesthesia, a doctor has to be prepared for a patient to slip into a level of sedation beyond that intended. In cases in which Gosnell’s objective was deep sedation, therefore, he should have been prepared for the patient to react as if under general anesthesia. Significantly, it is not uncommon for patients under general anesthesia to lose the ability to breathe on their own.

Gosnell’s clinic – without the drugs, staff, or equipment necessary to monitor, resuscitate, or assist his patients in breathing – was not even close to meeting NAF standards or any other standard of care. The evaluator noted that Pennsylvania requires that anesthesia be administered only by licensed personnel, a regulation that Gosnell failed to follow even during the NAF review.

Aside from these life-threatening practices, the evaluator noted numerous deficiencies in the clinic’s recordkeeping, including no notation of RH blood-typing and no record of sedation medications administered or the level of sedation. The clinic’s consent procedures also failed to meet NAF standards. Even with the evaluator watching, patients were not being informed of the risks of the medications, the sedation, or the procedure itself.

The evaluator testified that during the “counseling” she witnessed, a patient was told that Pennsylvania requires a 24-hour waiting period between when a patient is counseled and when the abortion can be performed. After stating the requirement, however, the counselor, according to the evaluator, said: “Okay, well. When do you want to come back for the abortion? Do you want to come back at 8 p.m.?” When the patient’s mother said, “but I thought we had to wait 24 hours,” the staff person responded, “if you want to come back at 8 p.m., you can come back at 8 p.m.”

Patient confidentiality is another important standard for NAF, and another that Gosnell flagrantly violated. The evaluator was troubled to find:

Throughout the office, there were patient charts everywhere. On desks, on this – the area in that upstairs sleeping area by the sleeping room. There were piles and piles and piles of medical records. That was – if that were in an area that was closed off and nobody had access to it, charts being stored there weren’t a big deal, but if there were patients in the sleeping room, who had to leave there to go to the restroom, they had full access to all of these people’s medical information if they wanted to look through it, it was very, very concerning to me. 

When asked if she had ever seen anything like the conditions and practices she observed at Gosnell’s clinic in any of the roughly one hundred clinics she has visited in the United States, Canada, and Mexico, the evaluator answered: “No.” Based on her observations, the evaluator determined that there were far too many deficiencies at the clinic and in how it operated to even consider admitting Gosnell to NAF membership. On January 4, 2010, she wrote to Gosnell informing him of NAF’s decision and outlining the areas in which his clinic was not in compliance. The evaluator told the Grand Jury that this was the first time in her experience that NAF had outright rejected a provider for membership. Usually, if a clinic is able to fix deficiencies and come into compliance with the standards, NAF will admit them. Gosnell’s clinic, however, was deemed beyond redemption.

We understand that NAF’s goal is to assist clinics to comply with its standards, not to sanction them for deficiencies. Nevertheless, we have to question why an evaluator from NAF, whose stated mission is to ensure safe, legal, and acceptable abortion care, and to promote health and justice for women, did not report Gosnell to authorities. To the jurors, the most appalling thing revealed by the NAF review is not that Gosnell tried to bluff his way through the application process with a borrowed nurse and some new lounge chairs. It is that he made no effort to address the grave deficiencies in his practice that had caused Karnamaya Mongar’s death.

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