Medical Board Revokes License of Doctor in 2019 Las Colinas Jail Death of Elisa Serna, 24

The Medical Board of California has revoked the license of one of two doctors who treated a woman who died at the Las Colinas jail in Santee.

Carol Ann Gilmore “engaged in gross negligence with respect to her care and treatment of” 24-year-old Elisa Serna, who was suffering from symptoms of drug and alcohol withdrawal yet was never treated for those symptoms, according to an order signed by a judge from the Office of Administrative Hearings, which hears cases of professional license discipline.

The order revoking Gilmore’s license was adopted by the medical board last week and will become effective on Sept. 13, according to the medical board’s disciplinary documents. It also states that Gilmore, who represented herself in the matter, did not appear at a hearing to present any mitigating evidence regarding the allegations.

Serna died on Nov. 11, 2019, five days after she was booked into jail. She was pronounced dead that night, shortly after she collapsed in her cell in the jail’s medical observation unit.

Her death prompted criminal charges of involuntary manslaughter against another jail doctor, Friederike Von Lintig, and a nurse, Danalee Pascua, though neither was convicted.

Gilmore was not criminally charged, but was referenced throughout the criminal case.

The accusation filed against Gilmore by the medical board’s executive director states that Serna reported her history of heroin and alcohol usage and later exhibited symptoms associated with withdrawal, such as frequent vomiting and seizures.

But Serna was never placed in withdrawal protocols and was accused by some medical staff members of faking her symptoms.

Serna requested to see a doctor after complaining of daily vomiting and other withdrawal symptoms, but Gilmore did not complete a physical examination of Serna and provided her medication to treat anxiety, according to the order, which refers to Serna as “Patient A.”

Citing testimony from Dr. James Rael, another doctor who reviewed the case, the order states that in Rael’s opinion, Gilmore’s treatment and care of Serna “constituted gross negligence because Patient A was experiencing acute withdrawal and (Gilmore) was aware of that but failed to treat or manage the withdrawal at all.”

Gilmore was also present on Nov. 11 just after Serna suffered one of several seizures she experienced that day. Gilmore ordered Ativan for Serna, which Rael stated “is not appropriate for treatment of either a seizure or for withdrawal and is simply not enough.”

Serna’s death also led to a federal wrongful death lawsuit filed by her family.

San Diego County and one of its health care contractors settled the civil suit earlier this year and agreed to pay $15 million to Serna’s family. The settlement included a series of non-monetary terms, which mandate the county to institute a series of reforms aimed at improving training for county jail personnel and revise protocols for inmates receiving medical care.

The medical board has also filed an accusation to revoke Von Lintig’s license, but a decision has not yet been rendered in that matter.