Women went to Dr. Kermit Gosnell to end their pregnancies. Many came away with life-threatening infections and punctured organs; some still had fetal parts inside them when they arrived at nearby hospitals in dire need of emergency care.
Doctors at the University of Pennsylvania Health System, which operates two hospitals within a mile of Gosnell's squalid abortion clinic in West Philadelphia, saw at least six of these patients _ two of whom died. But they largely failed in their legal and ethical duties to report their peer's incompetence, according to a grand jury report.
"We are very troubled that almost all of the doctors who treated these women routinely failed to report a fellow physician who was so obviously endangering his patients," wrote the Philadelphia grand jurors, who recommended a slew of charges against Gosnell and his staff in January.
The health system _ in apparent contradiction of the grand jury report _ released a statement saying that it had "provided reports to the authorities regarding patients of Dr. Gosnell who sought additional care at our hospitals" starting in 1999.
But the system's attorneys could only produce a single report for the grand jury. That involved 22-year-old Semika Shaw, who died at the university hospital of internal bleeding and sepsis after a botched abortion in 2000. Gosnell's insurers ultimately paid out a $900,000 settlement in that case.
Health system spokeswoman Susan Phillips later clarified the statement, saying "we have staff who specifically recall making oral reports" to state officials about Gosnell.
"Unfortunately, we have not been able to find additional written reports from these past years," she wrote in an email.
A Philadelphia doctor and suburban medical examiner who did blow the whistle said they never heard back from state officials, whose repeated lapses helped Gosnell to operate unchecked for years.
Prosecutors described Gosnell's clinic as "a house of horrors," where viable babies were killed with scissors, fetal remains were kept in jars and freezers, and dirty medical equipment was operated by unlicensed, often untrained and unsupervised employees. Gosnell himself was never certified in obstetrics and gynecology, only family practice.
Gosnell, 70, is jailed without bail and charged with eight counts of murder in the deaths of one patient and seven viable babies. Authorities say he also routinely maimed his clients, sometimes leaving them sterile and near death. He is due in court Wednesday for a formal arraignment.
The grand jury had scathing criticism for Pennsylvania's health and medical regulators for taking no action against Gosnell, despite reports that he was harming patients. But the panel also said too many local physicians had shirked their professional and legal responsibilities to report him and thus protect the lives of future clinic patients.
Pennsylvania law requires doctors to report abortion complications to the state Health Department. And the American Medical Association says "physicians have an ethical obligation to report impaired, incompetent and unethical colleagues."
But there were apparently no reports filed after Gosnell patient Marie Smith, 20, arrived at Penn Presbyterian Hospital in 1999, unconscious with an infection and fetal parts still inside her. Nor when Dana Haynes went to the emergency room at the Hospital of the University of Pennsylvania in 2006 with a perforated cervix, uterus and bowel, also with fetal parts inside. Both have spoken publicly about their cases.
And no reports were made after Karnamaya Mongar died at the university hospital in 2009 after Gosnell's unqualified staff allegedly gave her too much anesthesia, according to the grand jury. Gosnell is charged in Mongar's death.
Authorities say they know of at least two other Gosnell patients whose treatment at the university hospital went unreported.
These five cases, the grand jury alleged, are "just the tip of the iceberg." Latosha Lewis, a Gosnell employee, testified that emergency room staff at the university hospital told her they treated many Gosnell patients, the report said.
Penn's doctors had a moral duty to report but were likely discouraged by the inadequate disciplinary system, said Arthur Caplan, director of the university's Center for Bioethics.
"People in medicine don't see much happening to doctors who get reported," Caplan said. "You'll get more reporting if you fix this broken regulatory system. The two will go hand in hand."
The Pennsylvania Health Department _ one of the agencies criticized by the grand jury _ generally cannot confirm or deny receipt of abortion complication reports due to privacy issues, agency spokeswoman Holli Senior said. However, such reports would have been released to the grand jury for a criminal probe, she said.
Doctors who fail to file reports within 30 days of treating abortion complications are guilty of "unprofessional conduct" and could have their licenses suspended or revoked by the state Board of Medicine, according to the statute.
The State Department, which oversees the medical board, could not say if Penn doctors would be disciplined based on the grand jury report, spokeswoman Larissa Bedrick said. But she noted that prosecutions of years-old allegations are limited by lost records, poor memories and unavailable witnesses.
The State Department and the Board of Medicine were also blasted by the grand jury for failure to investigate or take action against Gosnell.
Reluctance to report a fellow doctor is not unusual, said Craig Klugman, a medical ethicist at the University of Texas Health Science Center at San Antonio.
Physicians who report peers for misconduct can jeopardize their own careers as well as those of the alleged offenders. They face possible retaliation, stressful legal proceedings and damaged relationships with other co-workers who may now fear they are being watched, Klugman said.
"We are encouraged to be whistleblowers, but whistleblowers never prosper," said Klugman, assistant director of the Center for Medical Humanities & Ethics. "There are a lot of personal sacrifices that often go along with it."
Two physicians did flag Gosnell's conduct. Dr. Donald Schwarz operated a pediatrics practice in West Philadelphia and referred some of his patients to Gosnell _ until they started coming back to him with the same sexually transmitted parasite, trichomoniasis.
Schwarz, then also head of adolescent services at Children's Hospital of Philadelphia, stopped referrals and hand-delivered a complaint to state secretary of health offices around 1996-97.
He never heard back. And there was no letter on file when the grand jury subpoenaed all Gosnell-related complaints. Schwarz told The Associated Press he did not retain a copy of the letter.
Schwarz said he didn't hesitate to report Gosnell once he connected the dots. But it was only after a third patient came in with the parasite and a tie to Gosnell that he came to grips with the idea that another doctor had caused his patients harm.
"It took me three times," Schwarz told the AP. "I could not believe that someone who was doing the abortion process wouldn't use clean and sterile equipment."
Schwarz became the city's health commissioner in 2008. Though many clinic issues were outside his jurisdiction _ they fell to the state _ he told the grand jury of his agency's missed opportunities to stop Gosnell.
A city health employee reported on the clinic's filthy childhood vaccination operation in 2008, resulting in Gosnell being suspended from the vaccine program. The report was never shared with other divisions. Schwarz has pledged better staff coordination and education.
Dr. Frederic Hellman, medical examiner for Delaware County in the Philadelphia suburbs, also tried to alert state authorities about Gosnell after discovering what he suspected was a mishandled and illegal late-term abortion in 2007.
An ailing Gosnell patient ended up at a Chester hospital, where she delivered a stillborn fetus that Hellman estimated to be 30 weeks old _ far beyond the state's 24-week limit for abortion.
Again, the state took no action on Hellman's report. He declined comment to the AP because of Gosnell's pending trial.
The grand jurors acknowledged that the responsibility for reporting abortion complications can get messy in busy emergency rooms where more than one doctor might treat a patient.
But in that case, the report said, hospitals should have a policy addressing the issue. One Penn doctor told the panel that such a procedure is now in place.
A hospital attorney also testified that a memo went out after Shaw's death in 2000 to remind doctors of the law; another memo went out last fall, just prior to the first physician's appearance before the grand jury.
Still, the egregious nature of the women's injuries should have spurred some kind of peer review or reporting mechanism, said Laurence McCullough, a professor and historian of medical ethics at Baylor College of Medicine in Houston.
"Physicians have a duty to protect patients from other physicians who are not competent," McCullough said. "That's been understood for centuries."