PHILADELPHIA - For years, state health officials missed some unsettling patterns at the three-story brick abortion clinic on Lancaster Avenue.
It was always open late, way past the time the pizza place next door closed at midnight. The women who emerged from it - often poor blacks and Hispanics - appeared dazed and in pain, and sometimes left in ambulances. The doctor who ran the clinic, Kermit Gosnell, had been sued at least 15 times for malpractice. Two women died while under his care.
But the dangerous practices went unnoticed, except by the women who experienced them. They were discovered entirely by accident, during a prescription drug raid by federal agents last February.
The clinic - now closed, with dead plants in its windows and old mail on its front desk - stands as a grim reminder of how degrading it was for the women who went there and how long state officials ignored their complaints.
On Wednesday, the Philadelphia district attorney, Seth Williams, indicted Gosnell on eight counts of murder in the deaths of seven infants and a Bhutanese refugee who died after a late-term abortion in 2009.
A grand jury report issued on the same day offered its own theory on why so little happened for so long.
"We think the reason no one acted is because the women in question were poor and of color," the report said, "and because the victims were infants without identities, and because the subject was the political football of abortion."
Kevin Harley, a spokesman for Gov. Tom Corbett, said Friday that the governor "was appalled at the inaction on the part of the Health Department and the Department of State," the two agencies that were responsible for overseeing the clinic.
Corbett has ordered an investigation into what happened, Harley said, and was awaiting recommendations. He said he did not know whether any of the officials named in the report would be fired.
"Semiconscious women scheduled for abortions were moaning in the waiting room or the recovery room, where they sat on dirty recliners covered with blood-stained blankets," the report said.
Confusion was a standard reaction to the conditions, women said in interviews last week, but many of the patients were young and lacked confidence and simply sat in silence.
"It was the first time for me, and I didn't know if that's how women usually are," said a young woman who had an abortion at the clinic in 1999 shortly after graduating from college.
The clinic had as little regard for the patients' dignity as it had for their safety. The doctor would arrive late, often after 8 p.m., leaving the untrained staff, including Gosnell's wife, Pearl, a cosmetologist, to sedate the women and administer labor-inducing drugs, the report said.
If labor began, the woman was asked to sit on a toilet, and the fetus would drop. It would be fished out later so as not to clog the plumbing, the report said. The remains of 45 fetuses were found at the clinic during the raid, according to the report. Some were stored in the staff's refrigerator.
Complaints against Gosnell date back to 1983, according to the grand jury report, but none moved state regulators to action. Some malpractice suits produced settlements that were paid by Gosnell's insurance company, including nearly $1 million paid to the family of Semika Shaw, a 22-year-old mother of two who died from an infection in 2002 after an abortion at the clinic.
The report details a sweeping pattern of negligence, with no inspector stepping foot inside the clinic for more than 16 years. Even the death of Karnamaya Mongar, a Bhutanese refugee who died after a procedure in 2009, was ignored.
Janice Staloski, a Health Department official, declined to investigate the death, saying the department had no authority to do so, the report said. The department's chief counsel, Christine Dutton, defended the agency's actions to the grand jury, stating bluntly, "People die."