The Pennsylvania Department of Health, which is charged with regulating healthcare facilities in the Commonwealth, had not inspected Dr. Kermit Gosnell’s clinic at 3801 Lancaster Avenue in Philadelphia in more than fifteen years. News of the death of Karnamaya Mongar after a botched abortion there led to no action. Similarly, the Pennsylvania Department of State, which regulates medicine and doctors within the Commonwealth, also failed to investigate Gosnell.

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