'Complete regulatory collapse': Why complaints about abortion doctor went nowhere

Hartwell said there had been "nothing extraordinary" about the Gosnell cases. One complaint came from a former employee who did not want to be called as a witness, which put its merit in question, he said. Shaw suffered a perforated uterus, a known risk in certain abortions, he said.

The insurer said that Gosnell had failed to notice he injured Shaw and that she had died of sepsis as a result, the grand jury found.

The department received a poor review in a study released last week from Public Citizen, a national consumer advocacy group. It found the state had taken no licensure action against 70 percent of doctors disciplined by Pennsylvania hospitals for poor performance between 1990 and 2009. That compared with 57 percent in New Jersey and 55 percent nationally.

Gosnell had been disciplined by at least one hospital. Penn Presbyterian Medical Center revoked his privileges before federal authorities raided his clinic in February 2010.

Nationally, medical boards are ill-equipped to act quickly. And, Penn's Caplan said, the culture "is oriented toward keeping doctors in practice, respecting their ability to earn a living, more than patient safety or weeding out inept practitioners."

"We really need to decide whether a system that lets a guy like this slip by doesn't really need a serious overhaul," he said.

Rieders, the malpractice lawyer on the Patient Safety Authority board, has lobbied for a state database that would allow patients to see whether their doctor had insurance, something they now have no way of knowing. And he would like judges to be able to issue injunctions when necessary to keep bad doctors from seeing patients. Fixing the existing system, he said, requires resources.

In his proposed budget, Corbett recommended cutting 13 people from the Bureau of Professional and Occupational Affairs. Funding would shrink 8.6 percent to $35.6 million.

Contact staff writer Chelsea Conaboy at 215-854-4193 or cconaboy@phillynews.com.

Inquirer staff writer Marie McCullough contributed to this article.