Doctor involved in Elisa Serna's prison death loses his license – San Diego Union-Tribune

The California Department of Public Health has revoked the license of Dr. Carol Ann Gilmore, who was among several medical professionals and sheriff's deputies under whose supervision Elisa Serna died in a San Diego County jail nearly five years ago.

The revocation by the California Medical Association came after a comprehensive investigation by state regulators.

The administrative decision, which does not name Gilmore, also came about two months after San Diego County agreed to a $15 million settlement to resolve a civil lawsuit accusing the Sheriff's Department of causing Serna's death at Las Colinas Women's Prison in 2019.

Gilmore could not be reached for comment. She did not respond to an email and her voicemail box was full.

The medical board accused her of failing to properly treat Serna, who had been arrested on drug and theft charges. Serna had told prison staff she was addicted to alcohol and heroin, but was not included in the department's detoxification protocols.

Serna died on the floor of her prison cell five days after her arrest.

According to the state health authority, Gilmore ignored Serna's symptoms and may be barred from practicing medicine.

“Despite her knowledge and repeated indications that the defendant was aware of Patient A's withdrawal from these substances, she simply did not treat this withdrawal as required by the standard of care,” the decision states.

“The defendant also failed to perform an examination of Patient A with blood tests and an EKG or to provide a treatment plan for Patient A,” it continues. “As a direct result of these failures, Patient A died from a lack of withdrawal treatment.”

Gilmore did not appear at the hearing and did not present any evidence to refute or explain the allegation, the medical board's August 16 decision said.

The doctor was also ordered to contribute nearly $30,000 toward the cost of the investigation.

Two medical professionals at the prison were criminally charged in connection with Serna's death, but Gilmore was not one of them.

Dr. Friederike Von Lintig and nurse Danalee Pascua were each charged with manslaughter following the suspect's death. The death was captured on surveillance video and presented to the court as part of the criminal proceedings.

A Supreme Court jury acquitted Pascua and could not reach a verdict against Von Lintig. Prosecutors declined to refile charges against the doctor and dropped the case.

The medical board has suspended Von Lintig's license and the state nursing board has filed charges against Pascua, but her license is still valid for now, according to records.

Although Gilmore was not charged by prosecutors, the state medical board believed her conduct was detrimental to Serna's well-being and launched an investigation and filed what is known as an indictment against her last year.

The decision, announced publicly this week, did not surprise Paloma Serna, Elisa's mother.

“Dr. Carol Gilmore had several chances to prevent Elisa's tragic end, as did every other person who interacted with her,” Serna said by email Friday.

“It was Gilmore's responsibility to initiate the necessary alcohol and drug rehabilitation measures,” she added. “Elisa suffered a painful death that could have been avoided. A simple call to 911 or arranging for her transfer to a hospital could have made a difference.”

Paloma Serna also said: “My family and I find comfort in the fact that Carol Gilmore will no longer be able to cause harm or take lives.”

Elisa Serna was 25 years old and five weeks pregnant when she died. Medical records from the five days she spent in custody before she died show that officers, nurses and doctors failed to respond appropriately to her symptoms.

She was the 15th person to die in the San Diego County Jail in 2019.

Since then, more than 70 more people have died in sheriff's custody, making San Diego County one of the deadliest prison systems in the state.