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.
