Interviews with state officials, former patients, lawyers, doctors, and activists on both sides of the abortion debate reveal that numerous opportunities to shine a light on Gosnell's problematic practice were missed or not pursued.
In 2005 and 2008, for example, Gosnell complied with Pennsylvania law by reporting to the Board of Medicine that was being sued for malpractice. The 2005 case, which alleged a patient suffered a perforated uterus and bowel, was dropped. The 2008 case, which alleged a patient had convulsions after receiving the wrong anesthesia, was settled.
Prosecutors with the state's bureau of professional and occupations affairs reviewed both cases and decided they did not warrant disciplinary action, said bureau commissioner Basil Merenda.
"In my experience, two cases in eight years is not a lot," explained supervising prosecutor Kerry Maloney. "That's not alarming."
The law requiring doctors to report malpractice suits took effect in 2002. Prosecutors could have checked public records of Gosnell's history in prior years.
If they had done so, prosecutors would have seen that Gosnell was named in eight more malpractice suits dating back to 1981, including one that involved a death. The patient died of a perforated uterus and bloodstream infection. The case was settled in 2002 for an undisclosed sum.
Prosecutors would also have noticed that Gosnell paid $10,000 in 2007 to settle a civil lawsuit for performing an abortion on a minor without parental consent. As a violation of the state's abortion control law, this would have triggered a suspension of his medical license pending an investigation.
"We can't prosecute what we don't know," Maloney said.
Gosnell has declined requests for comment.
