Janice Staloski could have stopped Kermit Gosnell, charged with eight murders at his abortion clinic.
As a Department of Health inspector in 1992, Staloski found problems at Gosnell's West Philadelphia abortion clinic, but gave her approval anyway, according to a Philadelphia grand jury report.
In 2002 and 2009, after two women had died following abortions and Staloski had become head of the office ensuring the safety of such clinics, she chose not to investigate either case.
And when federal drug officials raided Gosnell's clinic last February and discovered bloodstained recliners and parts of fetuses kept in jars, Staloski and others at the agency were slow to close it down, prosecutors said.
Of all the state officials involved, Staloski merits "special mention," the grand jury concluded. It paints her as a bureaucrat who failed to respond to decades of warning signs.
In an interview Monday, Staloski said that she was following orders and that it has been agonizing to see her 35-year state career capped by this incident. Staloski, who retired in March, said she did the best she could with policies that had been left unclear for years.
"I've done a very good job," she said from her home in Carbon County. "Looking at that report, it doesn't look like I've done a good job, but for years I have."
Gosnell was arrested Jan. 19 and charged with eight counts of murder in the deaths of Karnamaya Mongar in 2009 and seven infants whom prosecutors say he delivered live and then killed by severing their spinal cords. His wife, Pearl, and eight employees also face charges, with four accused of murder.
In a 261-page report, the grand jury took care to name the many city and state officials it said looked the other way while Gosnell profited from poor women. The women often came to him from out of state for late, illegal abortions, and left with injury and infection, the report says.
Prosecutors have alleged that Staloski, as a leader at the department, never once ordered an inspection on any of the state's abortion clinics. She denies that.
She acknowledged that Mongar's death in November 2009 should have prompted an inspection. Her attorney, Arthur Donato, said Staloski was a conscientious employee.
"When you're a line employee at a state agency, you're obligated to do that which you're instructed to do," he said. "The instructions here were ambiguous. There was no clear policy for people to follow."
Assistant District Attorney Joanne Pescatore, who is prosecuting the case with Christine Wechsler, said Staloski - more than others - was willing to acknowledge mistakes.
"She kind of fell on the sword," she said.
Prosecutors were alarmed by Staloski's reaction when federal drug agents on Feb. 18 raided Gosnell's clinic at 38th and Lancaster, believing he was illegally dispensing narcotic painkillers.
State health inspectors went along. One, a Staloski subordinate - Home Health division chief Cynthia Boyne - e-mailed to say that the District Attorney's Office was "badgering" the department to close the facility immediately, the report said.
"I'd say we were used," Staloski replied the next day, the grand jury found. She said Monday that she did not recall the context for that comment.
Wechsler said health officials seemed more concerned about how the case was affecting their office's image and workload than about the damage Gosnell's clinic was allegedly doing to patients.
"It defies explanation," she said.
Prosecutors said the Health Department should have requested a court injunction and padlocked the door that night.
Instead, they waited two weeks to initiate the process, the report said. In the meantime, the Board of Medicine suspended Gosnell's medical license but not before he performed at least two more abortions soon after the raid, prosecutors said.
Wechsler called the delay "unthinkable." Staloski said Monday that "people have due process" and that the decision to pursue closure was "moved up the chain of command" to the department's legal counsel.
When Staloski inspected Gosnell's facility in 1992, it was still state policy to conduct annual inspections of abortion clinics.
Soon the Health Department - to satisfy former Gov. Tom Ridge, an abortion-rights supporter - changed its policy. Under the new, unwritten protocol, annual visits were eliminated, but a complaint could prompt an inspection.
By 2002, Staloski had been named head of the Home Health division, which oversees abortion clinics and is part of the bureau she ultimately led. She received a call from an attorney representing the family of Semika Shaw, 22, who died after an abortion at Gosnell's clinic. The attorney later secured a $900,000 settlement for Shaw's family.
Staloski told the attorney there were no other complaints against Gosnell. But the grand jury report said the department record showed at least one, reported in 1996 from an attorney whose client suffered a perforated uterus.
Within weeks, a second call came in. Another lawyer was suing Gosnell.
The clinic hadn't seen an inspector in nine years, and Staloski did not send one.
She enforced a "do-nothing policy," the grand jury report said, and she did so "presumably with the knowledge and blessing of her bosses."
Staloski said the policy was to investigate any complaint that concerned the health and safety of individuals. But a reported event - even a death - "is not necessarily a complaint," she said.
On Nov. 24, 2009, a fax arrived in Staloski's bureau from Gosnell, reporting Mongar's death. Darlene Augustine, the registered nurse who received it, immediately notified her boss, Boyne. Boyne went to Staloski, the report said.
Augustine - whom prosecutors credited for trying to sound an alarm on Gosnell - told the grand jury that Staloski was "the ultimate decision-maker." But Staloski never gave the OK. Gosnell's clinic continued operating with no oversight for nearly three months, until the federal drug raid last February.
On March 27, Staloski retired as head of the Bureau of Community Program Licensure and Certification, collecting a lump sum of $143,790 and monthly payments of $6,715, according to records.
Staloski was not the only person highlighted by the grand jury for official indifference.
One section lists seven attorneys at the Department of State, which is charged with licensing doctors through the Board of Medicine, who knew of problems at the clinic and did nothing.
Among them was Juan Ruiz. According to the report, he closed a 2009 complaint against Gosnell from a woman who suffered a perforated uterus without reviewing it, saying it was a single incident that showed "simple negligence." He never consulted a national malpractice database that included cases from five women who successfully sued Gosnell for a similar injury, the grand jury found.
The report also criticized the many doctors who treated Gosnell's clients for complications from botched abortions but never alerted health officials, despite a state requirement to do so.
A few days after the release of the grand jury report, former Gov. Ed Rendell said he had pressed the Health Department to begin inspections again.
"The problem going forward has been cured," he said.
Facilities throughout the state, including several in Philadelphia, received surprise, hours-long visits in November and December followed by letters citing minor violations, if any.
The letters were signed by Boyne, the same person who led the Division of Home Health when Mongar died and the clinic was raided - and who is cited in the report as being part of the state's inaction.
Corbett spokeswoman Janet Kelley declined to make Boyne or Ruiz available for interview. She noted that Corbett has asked his nominee for health secretary to review the case, and the governor will discuss those recommendations soon.