PHILADELPHIA (CN) - "A policy of inaction" at Philadelphia's Department of Public Health allowed notorious abortion doctor and accused murderer Kermit Gosnell to operate his filthy clinic despite repeated warnings about "deplorable" conditions, says the estate of a former Gosnell patient, who was a refugee from Bhutan.
Gosnell was arrested in January and charged with murder after a grand jury found that he routinely delivered live babies during the third trimester, then killed them by severing their spinal cords with scissors.
According to the Report of the Grand Jury, Gosnell's Women's Medical Society, housed in a nondescript building on a quiet corner of west Philadelphia, was a filthy house of horrors where fetal remains were scattered among bloodstained furniture, dirty medical equipment and roaming cats, who defecated freely.
It was, according to the Report, "a baby charnel house."
The grand jury recommended that Gosnell be charged with multiple counts of infanticide and a slew of related offenses.
"Dr. Gosnell didn't just kill babies. He was also a deadly threat to mothers," according to the report, which says Gosnell allowed unlicensed workers to pump powerful sedatives into patients willy-nilly.
One of those mothers was 41-year-old Karna Maya Mongar, whose heart stopped hours after she received "repeated unmonitored, unrecorded intravenous injections" of Demerol, according to the report.
Mongar's daughter sued the City of Philadelphia Department of Public Health and City Health Commissioner Dr. Donald Schwarz in Federal Court.
Yashoda Devi Gurung says her mother's death could have been prevented if the Department of Public Health had heeded repeated warnings from city health workers about the deplorable conditions at Gosnell's facility.
In August 2003, a sanitation worker received an anonymous tip "that aborted fetuses were stored in paper bags in the employee refrigerator at Gosnell's clinic," but the Public Health Department failed to properly follow up on the report, the estate says.
In July 2008, a year before Mongar died, city employee Lori Matijkiw inspected Gosnell's clinic and "took note of the dirty and hazardous conditions of the office, the lack of required documentation of refrigerator temperatures, bloody fetuses stored in a freezer just below ice trays containing chicken pox vaccines, and 'red fluid spilled/frozen on the floor of the freezer,'" according to the complaint.
Despite this alarming report, "nothing was done about the dirty conditions or the storage and leakage of bloody fetuses," Mongar's daughter says.
In October 2009, a month before Mongar's death, Matijkiw returned "and found that it was still filthy, still contained expired vaccines and still lacked appropriate refrigerator temperature documentation," the complaint states.
"Matijkiw also discovered several more deplorable conditions. She discovered that the doctor on site ... was not licensed in Pennsylvania and falsely claimed to have a Delaware medical license," according to the complaint.
"Most disturbing is Matijkiw's report that she saw patients being escorted into the procedure area of the clinic despite the fact that Gosnell was not on the premises," the complaint states.
But that second scathing report was never shared with the appropriate officials, and Gosnell's clinic continued to operate, the estate says.
About a month after that report, "Karna Maya Mongar found herself in the same situation, being taken to the procedure area of the clinic to be administered powerful drugs by unlicensed personnel with no physician present in the procedure area or present in the building," the complaint says.
According to the grand jury report, Mongar's heart stopped hours after she was sedated. She was taken off life support the next day, but was probably brain dead by the time paramedics arrived at the clinic, according to the report, which notes that medics struggled to remove her from the building because of cluttered hallways and a padlocked emergency exit.
The Department of Public Health "has established a practice and policy of not relaying dangerous and hazardous conditions between departments to allow for the correction and elimination of those conditions," the estate says, adding that the agency operates on "deeply flawed policies and practices."
Mongar's daughter says the Department of Public Health's failure to share reports among its 12 or more divisions "was not the discrete happenings of a few low-level employees. Instead, this was a policy throughout the Philadelphia Department of Public Health."
That "policy of inaction," the estate says, "ultimately cost Karna Maya Mongar her life."
Her daughter seeks punitive damages for civil rights violations, claiming the city failed to enforce policies "that allow ... employees to share reports of hazardous and/or unsafe conditions to other divisions of PDPH."
The gruesome, 281-page Report of the Grand Jury lodged similar accusations: "Had the Philadelphia Department of Public Health reported to state officials all that its employees knew or suspected about filthy facilities, fraud, the unlicensed practice of medicine, anesthesia chosen by patients based on cost, infectious waste improperly handled and stored, and vaccines stored next to medical waste, perhaps state authorities would have taken action against Gosnell and Women's Medical Society."
The estate is represented by Bernard Smalley with the Tucker Law Group.
The Philadelphia Inquirer reported last week that six workers from Gosnell's clinic have pleaded guilty to related charges.
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