Medical Association revokes doctor's license in 2019 Las Colinas Prison Death of 24-year-old Elisa Serna

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

According to an order by a judge in the Office of Administrative Hearings, which hears disciplinary cases related to licensure violations, Carol Ann Gilmore was “grossly negligent in the care and treatment” of 24-year-old Elisa Serna, who suffered from drug and alcohol withdrawal symptoms but was never treated for those symptoms.

The decision to revoke Gilmore's license was approved by the medical board last week and will take effect Sept. 13, according to the board's disciplinary documents, which also state that Gilmore, who represented herself in the matter, failed to appear at a hearing to present mitigating evidence to the allegations.

Serna died on November 11, 2019, five days after being admitted to prison. She was pronounced dead that same evening, shortly after collapsing in her cell in the prison's medical monitoring unit.

Her death led to another prison doctor, Friederike von Lintig, and a nurse, Danalee Pascua, being charged with manslaughter, but neither was convicted.

No criminal charges were filed against Gilmore, but he was mentioned throughout the criminal proceedings.

The indictment filed against Gilmore by the executive director of the medical commission states that Serna reported her past use of heroin and alcohol and later exhibited withdrawal symptoms such as frequent vomiting and seizures.

But Serna was not given withdrawal protocols and some members of the medical staff accused her of faking her symptoms.

Serna had asked to see a doctor after complaining of daily vomiting and other withdrawal symptoms, but Gilmore did not perform a physical exam on Serna or give her medication to treat her anxiety, according to the order, which refers to Serna as “Patient A.”

Citing testimony from Dr. James Rael, another physician 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 symptoms and (Gilmore) was aware of this but failed to treat or in any way manage the withdrawal symptoms.”

Gilmore was also present on November 11, shortly after Serna suffered one of several seizures she experienced that day. Gilmore prescribed Ativan for Serna, which Rael said was “neither effective at treating a seizure nor withdrawal and is simply not sufficient.”

Serna's death also led to her family filing a wrongful death lawsuit in federal court.

San Diego County and one of its health care providers settled the civil suit earlier this year, agreeing to pay $15 million to Serna's family. The settlement included a series of non-monetary conditions requiring the county to implement a series of reforms aimed at better training county jail staff and revising protocols for inmates receiving medical care.

The Medical Association has also filed a motion to revoke Lintig's license, but a decision has not yet been made.