One employee from Pennsylvania’s Department of Public Health did alert her supervisors about the disgusting conditions at Kermit Gosnell’s Women’s Medical Society clinic. No action was taken against Gosnell.

Lori Matijkiw went to Gosnell’s clinic in July 2008 to conduct an AFIX visit, or vaccine inspection. He provided children’s vaccines through a program by the Philadelphia Health Department’s Division of Disease Control using the name “Family Medical Society.” The grand jury saw emails dating back to August 2011 stating Gosnell was suspended numerous times “for failing to maintain logs and for storing vaccines in filthy, unsuitable refrigerators, and at improper temperatures.”

Matijkiw immediately contacted her superiors, identified by the grand jury as Program Manager Lisa Morgan and Medical Director Dr. Barbara Watson. The details should have provoked an immediate investigation:

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.

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.

The city health department suspended Gosnell from the program, but did nothing else. One employee said the vaccines must be separate from other medical products. The grand jury concluded the employee meant the containers filled with dead babies. 

Another visit did not happen for another year.Matijkiw visited again on October 7, 2009 and found the same deplorable conditions and actually sat down with one of the fake doctors Gosnell employed. Eileen O’Neill was an unlicensed doctor in Pennsylvania and Gosnell paid her in cash. She treated patients and prescribed them medications, which is against the law. The interview with Matijkiw should have raised red flags with her boss:

In it [the report to Morgan] Matijkiw described a two hour meeting with “(Dr.) O’Neill” (the parentheses were in her original email). During the visit, Matijkiw learned that O’Neill had no understanding of the vaccine program. O’Neill reportedly believed that the free children’s vaccines could be given to adult patients and to those with private insurance. Matijkiw noticed that one of the free vaccines was given to Gosnell’s daughter.

In addition, Matijkiw noticed that the clinic listed 20 children on Keystone Mercy, a Medicaid health plan. Matijkiw wrote that three of the “children” were almost 19 years old, and one had private insurance through Aetna. She wondered if any of them had ever been in the clinic. She also said that O’Neill was improperly trying to count abortion patients as vaccination patients.

In response to questioning by Matijkiw, O’Neill admitted that she was not licensed in Pennsylvania. She falsely claimed to have had a Delaware license, which she said she let lapse. When Matijkiw asked who in the practice treated children, O’Neill replied: “They don’t come in.” Yet Gosnell and O’Neill claimed to be providers of children’s vaccines.

Matijkiw described the filthy office and how Gosnell never improved conditions from the previous year. She noted to Morgan she saw patients go into the procedure area even though Gosnell was not there: “If Dr. Gosnell was out of the office and [O’Neill] had to call the other physician’s assistant on his cell phone and leave a message for his MA#, why were patients in the procedure area?”

This warning occurred in October 2009; Matijkiw’s superiors did absolutely nothing to stop Gosnell. Karnamaya Mongar died at the clinic a month later.