Time and time again, authorities alerted to Kermit Gosnell's filthy and macabre abortion clinic - and to the injured, diseased or dead women he left in his wake - failed to rattle the alarm bells loudly enough to shut his house of horrors, the district attorney's grand-jury report found.
"The Department of State literally licensed Gosnell's criminally dangerous behavior," the report concluded, and the state Department of Health "gave its stamp of approval to his facility."
The "callous killing of babies outside the womb" persisted "for years" because officials looked the other way, the report said.
The grand jury also found that people at the city's Department of Public Health and city hospitals also learned of warning signals, but failed to act.
According to the grand jury's report:
* The State Department, whose Board of Medicine licenses and oversees physicians, "could have stopped Gosnell single-handedly." About a decade ago, a former Gosnell employee filed a complaint detailing the clinic's unsterile conditions and unlicensed workers. But the department dismissed the complaint after an investigation, which did not include an inspection.
Shortly after, the department received a report of the death of Semika Shaw, 22, and closed the case without investigation, concluding that her death was an "inherent" risk that did not warrant suspending Gosnell's license.
* As for the Pennsylvania Department of Health, the grand jury found it "deliberately" chose not to enforce laws that would have protected Gosnell's patients.
After it approved the opening of Gosnell's clinic in 1979, the department failed to conduct a site review until 10 years later, when violations were apparent.
Then, after 1993, the Health Department "abruptly decided, for political reasons, to stop inspecting abortion clinics at all," the grand-jury report found, leaving "clinics to do as they pleased."
One person who complained to the Health Department in 1996 or 1997 was Donald Schwarz, then a Children's Hospital of Philadelphia doctor and now the city's health commissioner. Schwarz yesterday recalled that he had referred teenage patients to Gosnell for abortions in the mid-1990s but stopped after he noticed patients coming back with the same venereal disease.
He hand-delivered a complaint to the office of the Pennsylvania Secretary of Health, but never heard back from the department.
The grand jury also noted that in 2007, Delaware County Medical Examiner Frederic Hellman reported to the Health Department that Gosnell performed an illegal abortion on a 14-year-old girl carrying a 7-month-old baby.
The department also received notice of the death of Karnamaya Mongar, 41, in 2009. "Yet not one of these alarm bells - not even Mrs. Mongar's death - prompted the department to look at Gosnell," the grand-jury report said.
Kevin Harley, spokesman for newly sworn-in Gov. Corbett, said the administration is "shocked and disappointed" by the two departments' inactions. He said it was "too soon to tell" if anyone would be fired or disciplined.
* An employee at the city's Department of Public Health, which does not regulate doctors or medical facilities but is supposed to protect the public's health, had alerted her bosses twice "that things were seriously wrong at Gosnell's clinic," but nothing was done about it. Her second notice was a month before Mongar died.
The grand jury found that although Schwarz, who testified before it, accepted regret and personal responsibility, he "seemed to excuse department employees who ignored the serious" health threats and "provided feeble excuses for their inaction."
Schwarz, the city's health commissioner since 2008, said yesterday that his department would work better to report complaints to state officials. He stressed that the public should know that Gosnell's clinic was "abnormal" and "not the norm for abortion care."
* The grand jury also found that city hospitals failed to report complications from Gosnell abortions as they are required to do under state law. While the Hospital of the University of Pennsylvania correctly reported that a patient who came to HUP died after Gosnell botched an abortion on her a decade ago, Penn facilities failed to report complications from at least three other Gosnell patients who later went to its facilities.
A Penn Medicine spokesman issued a statement yesterday that said in part: "Starting in 1999, Penn Medicine provided reports to the authorities regarding patients of Dr. Gosnell who sought additional care at our hospitals and we continue to monitor our reporting procedures."
The grand jury suggested legislative hearings to examine these issues, and proposed 15 recommendations, including:
* There should be no statute of limitations for infanticide.
* The state Department of Health should license abortion clinics.
* Because Gosnell "cut the feet off the fetuses he aborted and kept them in a row of jars," the grand jury recommended that the Abortion Control Act should be amended to prohibit the mutilation of fetal remains.