The Grand Jury report of its investigation into Kermit Gosnell’s baby slaughter house in Philadelphia reveals the greedy neglect of the city of Philadelphia.
Once again, like the state of Pennsylvania, the city of Philadelphia had more than enough information gathered by reliable employees to shut down Gosnell’s serial killing factory. But they declined to act.
Beginning on page 202, the report details inspections of Gosnell’s clinic by nurses there to verify his participation in a free vaccine program run by the city.
The City of Philadelphia employee who did notice and report the abysmal conditions she observed at Gosnell’s clinic was a registered nurse named Lori Matijkiw. Matijkiw conducted what the Health Department calls an “AFIX” visit, or vaccine inspection, in July 2008.
Using the name “Family Medical Society,” Gosnell purported to be a provider of children’s vaccines under a program administered by the Philadelphia Health Department’s Division of Disease Control. The doctor’s history with the program, however, was rocky. Emails going back to August 2001 reveal that he was suspended from the program repeatedly for failing to maintain logs and for storing vaccines in filthy, unsuitable refrigerators, and at improper temperatures.
Health department employees who visited the clinic between 2001 and 2007 recorded that they dealt with “Drs.” O’Neill and Massof, but never Gosnell. These inspectors noted problems with the refrigerator, the clinic’s record-keeping, and expired vaccines. They were apparently oblivious, however, to other obvious deficiencies that did not relate directly to vaccines.
On July 16, 2008, at 1:30 p.m., Matijkiw made a vaccine inspection visit to Gosnell’s clinic. Unlike the inspectors before her, she did not simply stick to her narrow, assigned task of inspecting vaccines and their storage units. She took seriously her broader duty to protect public health. Following her visit to Gosnell’s facility, she reported on a multitude of deficiencies she found.
In an email to her superiors at the Philadelphia Department of Public Health – whom we have identified as Program Manager Lisa Morgan and Medical Director Dr. Barbara Watson – Matijkiw reported that she had trouble even scheduling an appointment. No one answered the phone at the clinic, and when they finally did, they told her that “Dr. Massof” was on leave. After she finally scheduled an appointment, neither Gosnell nor the office manager was at the facility when she arrived. The two women who were there, she wrote, were “clueless.”
While Matijkiw waited for the women to try to contact Gosnell, she noticed signs taped to the front desk. One was a price list for abortions detailing the costs for different gestational ages, with a price list for four different levels of anesthesia [Appendix C]. A third sign announced: “If you have the pre-procedure blood tests and work up done, and change your mind, you are still responsible for the costs of the tests.” Matijkiw wrote down everything she observed.
She noted that the office was “not clean at all, and many areas of the office smell like urine.” She reported a “dark layer of dust” on the baseboards and described the “enormous” fish tanks, filled with murky water. In the refrigerator, she found expired vaccines – one with an expiration date of March 2006, another 2005. The temperature log, which was supposed to record the refrigerator temperature every day, had not been marked since the second day of June – a month and a half earlier. On top of the refrigerator, she found a stack of temperature logs, already filled out, showing readings twice a day, with no initials, time, or month.
Matijkiw wrote that Tina Baldwin showed her to a freezer in a “lab” (quotation marks are in the original email) on the second floor. Inside she found “3-4 large plastic containers with blood-colored frozen contents, wrapped in blue chux.” She described a “red fluid spilled/frozen on the floor of the freezer.” Chicken pox vaccines were stored in an ice tray above the containers of bloody fetuses.
The clinic staff told Matijkiw that “Dr. Massof” had left abruptly in June and that Gosnell was unfamiliar with the program. When Matijkiw asked to see files showing vaccines administered, the staff told her they had none. She reported to her bosses that she looked up Gosnell on the state website and found that he had been disciplined in the past.
Based on Matijkiw’s report, the city health department suspended Family Medical Society – once again – from the vaccine program, but took no further action. In fact, a little over a year later, the department was considering re-enrolling the clinic in the program. A note by one employee in August 2009 recorded: “Site was told they need to purchase a new unit to store their vaccines completely SEPARATE from all other medical products” – an apparent reference to the containers filled with fetuses. Other than assuring that vaccines were not placed in the same freezer, the city health department showed no concern about the stored fetuses or the dripping frozen blood observed by Matijkiw.
That was just the first visit. After that visit and report, the city took no action. Ms. Matijkiw visited the clinic again a year later and again wrote a report detailing all that was going wrong in this clinic. And again no action was taken.
Matijkiw’s email to Morgan should have resulted in immediate action. Just like her report the year before should have triggered a response. If nothing else, Matijkiw’s supervisors should have passed her information about the unsanitary conditions and the fetuses in the freezer to another division within the city health department with jurisdiction over such matters.
They should also have reported Gosnell and O’Neill to the Department of State’s Board of Medicine, based on the evidence apparent to Matijkiw that patients were being treated in Gosnell’s absence and that O’Neill was practicing without a license. Yet the city health department did nothing.
Why did the city do nothing? Because access to abortion, shut up. The clinic was eventually ejected from the vaccination program and the emails describing the charnal house of horrors were put in the file and the case was closed. Nothing else was done.
What about waste? One of the common descriptions of Gosnell’s clinic is that there were dead baby bodies and medical waste lying about the clinic, everywhere. The freezers were packed with it, the basement was full of boxes of bodies, blood and placentas. There were baby bodies in cut off milk jugs in refrigerators, feet in jars. The place reeked of death and blood. Everything was filthy. I’m assuming that the city of Philadelphia inspects restaurants for cleanliness, do they not inspect medical facilities? They certainly require a plan for disposing of medical waste (dead baby bodies).
The key here is that they also require a fee.
The city of Philadelphia requires medical offices to pay a fee to submit a plan for medical waste. And then they are done. No enforcement, no inspections. Just the plan and the fee. The city of Philadelphia is just after the revenue NOT making sure the city’s medical offices are actually safe of it’s inhabitants.
When the Grand Jurors toured the facility in 2010, boxes of waste were still sitting on the basement floor. Gosnell still stored aborted fetuses in plastic containers in the freezer. Employees described a stench emitted by bags of fetal tissue that piled up in the clinic.
Commissioner Schwarz tried, unsatisfactorily, to explain why the city never enforced the regulations that purport to protect staff, patients, the community, and the environment. Protection of the public, according to Dr. Schwarz’s testimony, was not the real intent behind the regulations. The impetus for requiring doctors to have infectious waste plans approved by the city was not public health; it was revenue.
This is the official direction given to city employees tasked with enforcing these regulations:
The department was told, apparently, to collect the money, make sure the plan came in, get the fee, and not enforce, that is don’t take action against people but remind them. This is a revenue generating activity.
Gosnell’s clinic was KNOWN to be violating the medical waste code, but they were concerned only about the fees. Never you mind that there is a squalid, filthy clinic dishing out drugs, contagion and death to the poor and minorities among you. There are FEES to be paid.
Again I call into question ALL medical facilities in the city of Philadelphia. ALL of them need to be reinspected.
Remind me to never get sick in Pennsylvania.