State regulators are seeking to discipline a second physician who treated Elisa Serna in the days before her 2019 death in the Las Colinas women’s jail in Santee.
The action filed by the Medical Board of California is a civil proceeding, unlike the criminal charges filed against another doctor and nurse in the Serna case.
According to what’s called an accusation, Dr. Carol Ann Gilmore should have her license revoked, or at least suspended, for what regulators call her negligent treatment of Serna, a 24-year-old woman who died days after being booked into San Diego County jail.
The filing does not identify Serna by name, referring to her only as Patient A, but the allegations spelled out in the seven-page document match the circumstances of Serna’s death on Nov. 11, 2019, and the other doctor and nurse facing separate charges of involuntary manslaughter.
State regulators are seeking a hearing before the medical board to determine whether to suspend or revoke Gilmore’s license.
Licensees are permitted to dispute accusations or negotiate a lesser discipline, much like in a civil or criminal court. The next step in the proceeding has not yet been scheduled.
Serna was arrested Nov. 6, 2019. She told deputies at the time she was booked that she was a regular user of heroin and alcohol, with her last use being some two hours before booking, and that she was five weeks pregnant.
An undated photo of Elisa Serna
(Family photo)
But four days later, despite repeated vomiting and other symptoms, Serna was placed in general housing and not under the department’s drug-withdrawal protocols. She died alone in her cell after falling and striking her head.
According to the accusation, Gilmore should have done more to treat Serna.
“Respondent did not refer Patient A to the emergency department for treatment of her active substance use withdrawal during pregnancy, did not order a stat comprehensive blood panel, complete blood count, urinalysis or electrocardiogram and did not order IV fluids,” the medical board said.
The civil action comes just months ahead of the criminal trial against Dr. Friederike Von Lintig and nurse Danalee Pascua, who each pleaded not guilty and are scheduled for trial in January.
The civil suit filed by the Serna family is expected to go to trial in February.
Both Von Lintig and Pascua have already been disciplined by civil regulators; their licenses were suspended in July.
In an email to the sheriff’s chief medical officer nine days after Serna died, Von Lintig described Gilmore as frequently disparaging the people under her care and accusing them of faking medical symptoms.
Von Lintig also blamed Gilmore for failing to properly inform her of Serna’s medical condition when she arrived on scene in the hours before Serna died.
“Dr. Gilmore said nothing but ‘I guess you can take over from here’ and left (medical) without giving me a sign-out about the previous events,” Von Lintig wrote.
On the day she died, Serna had suffered from vomiting, dehydration and other symptoms of drug withdrawals, records show, but she was nonetheless being transferred from the medical ward to the main housing area.
“While seated in a wheelchair outside her isolation cell, Patient A’s body suddenly stiffened with her head resting on the back of her chair and her legs dangling on the floor,” the accusation states.
The jail staff summoned medical help, and Gilmore appeared minutes later. After consulting with the nursing staff, Gilmore prescribed Serna an anxiety medication, the accusation says. She did not speak with Serna or perform a physical examination, it adds.
“Despite assuming Patient A’s care, respondent did not at that time or anytime thereafter formulate and/ or document an assessment or plan of care for Patient A,” state regulators said.
Serna was found unconscious in her cell later that night and subsequently pronounced dead.
San Diego attorney Julia Yoo, who represents the Serna family in its litigation against San Diego County, said regulators were correct to intervene in Gilmore’s licensing status.
“Doctors should not practice medicine when they refuse to provide the most minimum amount of care to a dying patient,” Yoo said. “It was the right decision by the state of California to protect its citizens.”
Gilmore currently holds a physician and surgeon’s license, records show.
She graduated from the University of Texas Medical School at Houston in 1983 and first received her license from the state of California the following year.
She lives in Escondido but could not be reached for comment.
