The woman had just had an abortion at Kermit Gosnell's clinic. Her heart had stopped and ambulance workers couldn't get her out a locked clinic door. So they cut a padlock and had to wait for staff to find a key to a second lock.
That account was one of many problems cited in an order released yesterday by the Pennsylvania Department of Health.
The agency found that Gosnell's West Philadelphia clinic had no easy way to get patients on stretchers out of the building. The clinic also lacked required medical equipment and drugs for emergency resuscitation, state investigators found.
The clinic, a rambling, three-story structure at 3801 Lancaster Ave., was closed on Feb. 22, after a raid by federal drug agents and state authorities. Gosnell's medical license was also suspended.
The latest order cites 14 broad categories in which Gosnell committed multiple violations of state law. Each violation is grounds for permanently shutting down the clinic, the order said. Gosnell has 30 days to respond.
His Philadelphia lawyer, William Brennan, said, "We're in the process of reviewing the counts and we'll address them in the appropriate time frame."
Gosnell, 69, a 1966 graduate of Jefferson Medical College who has been performing abortions in West Philadelphia since the early 1970s, has in recent years done about 1,000 abortions annually, state records show. Since 1981, Gosnell has faced 46 civil lawsuits, 10 for medical malpractice, including one case in which a patient died. He is now being investigated by federal, state, and city law enforcement authorities.
The state Health Department's findings add chilling detail to the earlier medical-license suspension order calling the clinic's "deplorable and unsanitary" conditions "a clear danger to the public."
Health officials reviewed records of 11 patients on whom Gosnell performed abortions between Nov. 19, 2009, and Feb. 19 - the day after the clinic was raided. State investigators found that nine of those women were in the second trimester of pregnancy - 14 or more weeks.
Three of those patients developed severe complications and had to be rushed by ambulance to a hospital.
In all three cases, the Health Department order says, ambulance personnel found doors and halls that could not accommodate a stretcher, and locked exit doors - one of which was blocked by "an IV pole, a wheelchair, and a broken office chair."
Two patients had to be helped to walk out to the ambulance. The rescue of the third patient, who was unconscious, involved cutting a padlock and finding a key.
Although the order does not identify the 11 patients by name, it says this unconscious patient was 19 weeks' pregnant, and had the abortion on Nov. 19. That matches Karnamaya Mongar, 41, of Woodbridge, Va., who developed a fatal heart arrhythmia after being given multiple doses of narcotic painkillers, according to the Medical Board.
In an interview last month, Mongar's brother, Damber Ghalley, recalled his shock at seeing his sister being taken out a back door of the clinic on an ambulance stretcher. "I was crying," Ghalley said. "My sister was fine before that."
Among other violations found by the Health Department's investigation:
Emergency resuscitation and monitoring equipment such as a heart defibrillator, breathing tubes, and a blood oxygen gauge were nonexistent or broken. The only suction source for clearing a blocked airway was the same one used for early abortions; it had no inspection sticker and corroded tubing.
Drugs to treat a patient for cardiac arrest, allergic reactions, or excessive bleeding were not stocked.
An oxygen mask and tubing were covered "in a thick gray layer" of apparent dust.
Gosnell had no backup physician, and patients in the recovery area were not monitored by a nurse.
The clinic did not submit fetal tissue from the nine late abortions to a pathologist to verify the fetus was not "viable" - unable to survive.
The clinic did not do blood and urine tests required to make sure patients could safely undergo abortions.
The Health Department also found that, even though Gosnell knew he was required to report serious complications to the state within 24 hours, he did not do so with the patient who went into cardiac arrest Nov. 19.
And Gosnell apparently lied on the quarterly reports he had to submit. For the last quarter of last year, he listed only two second-trimester abortions, yet his facility "provided at least six second-trimester abortions" during that period, the state order said.
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