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You may need to create a new email yourself." data-email-share-nonce="dde2745302" data-email-share-track-url="https://www.sandiegouniontribune.com/2024/08/24/doctor-involved-in-elisa-serna-jail-death-loses-medical-license/?share=email"><span></span><span class="sharing-screen-reader-text">Click to email a link to a friend (Opens in new window)</span></a></li><li class="share-reddit"><a rel="nofollow noopener noreferrer" data-shared="" class="share-reddit sd-button share-icon no-text" href="https://www.sandiegouniontribune.com/2024/08/24/doctor-involved-in-elisa-serna-jail-death-loses-medical-license/?share=reddit" target="_blank" title="Click to share on Reddit" ><span></span><span class="sharing-screen-reader-text">Click to share on Reddit (Opens in new window)</span></a></li><li class="share-end"></li></ul></div></div></div></div></div></header><div class="article-content"><div class="article-content-wrapper"><div class="header-features default"> <figure> <div class="image-wrapper"><img alt="Paloma Serna holds up a sign about her daughter, Elisa Serna, who died in a San Diego County jail in 2019, during a rally last year in El Cajon. (U-T) " title="Paloma Serna holds up a sign about her daughter, Elisa Serna, who died in a San Diego County jail in 2019, during a rally last year in El Cajon. (U-T) " subtitle="" class="lazyload size-article_feature" data-sizes="auto" data-src="https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=525" data-srcset="https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=525 620w,https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=660 780w,https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=863 1020w,https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=1080 1280w,https://www.sandiegouniontribune.com/wp-content/uploads/2024/08/SUT-L-elisa-serna-vigil-1.jpg?w=1569 1860w" ></div> <figcaption> Paloma Serna holds up a sign about her daughter, Elisa Serna, who died in a San Diego County jail in 2019, during a rally last year in El Cajon. (U-T) </figcaption> </figure> <div class="meta"><img class="avatar avatar-85 photo coauthor-avatar lazyload size-85x85" data-sizes="auto" data-src="https://www.sandiegouniontribune.com/wp-content/uploads/2024/06/Jeff-McDonald.webp?w=85" data-srcset="https://www.sandiegouniontribune.com/wp-content/uploads/2024/06/Jeff-McDonald.webp?w=85 85w" alt=""><div class="coauthor-avatar-container"><div class="byline">By <a href="https://www.sandiegouniontribune.com/author/jeff-mcdonald/" title="Posts by Jeff McDonald" class=" author-name" rel="author">Jeff McDonald</a> | <a href="mailto:jeff.mcdonald@sduniontribune.com">jeff.mcdonald@sduniontribune.com</a> | The San Diego Union-Tribune</pre></div><div class="time">UPDATED: <time datetime="2024-08-24 16:34:06">August 24, 2024 at 4:34 PM PDT</time></div></div></div></div><div class="article-body"><div class="body-copy"><div class="wp-remixd-voice-wrapper"><script type="text/javascript" id="remixd-audio-player-script" src="https://tags.remixd.com/player/v5/index.js?cb=%%CACHEBUSTER%%" charset="utf-8" async></script></div><p>California medical regulators have revoked the license of Dr. Carol Ann Gilmore, who was among the many healthcare professionals and sheriff’s deputies under whose watch Elisa Serna died in a San Diego County jail almost five years ago.<p>The revocation issued by the Medical Board of California came after an extensive investigation by state regulators.</p><p>The administrative decision, which does not identify Gilmore by name, also came some two months after San Diego County agreed to a <a href="https://www.sandiegouniontribune.com/2024/07/01/san-diego-county-settles-elisa-serna-jail-death-lawsuit-for-15-million-and-limited-federal-oversight/">$15 million settlement</a> to resolve a civil lawsuit accusing the Sheriff’s Department of causing Serna’s death in the Las Colinas women’s jail in 2019.</p><p>Gilmore said she previously decided to stop working as a physician.</p><p>“I officially notified the medical board that I am retired as of 10/30/2023,” she wrote in an email. “I practiced medicine for 37 years without a single patient complaint or lawsuit.”</p><p>She was <a href="https://www.sandiegouniontribune.com/2023/10/28/state-medical-board-seeks-to-revoke-or-suspend-license-of-second-doctor-in-elisa-sernas-death-in-jail/">accused by the medical board</a> of failing to properly treat Serna, who had been arrested on drug and theft charges. Serna had told jail staff that she was addicted to alcohol and heroin but was not placed into department withdrawal protocols.</p><script id="11982501ceb44352bd1e95848c612274"> (new Image()).src = 'https://capi.connatix.com/tr/si?token=8b64ff35-2d21-481e-88ae-8562dded85bd&cid=1ffe15d6-eb53-11e9-b4d2-06948452ae1a'; cnx.cmd.push( function() { cnx( { playerId: "8b64ff35-2d21-481e-88ae-8562dded85bd" } ).render( "11982501ceb44352bd1e95848c612274" ); } );</script><p><a href="https://www.sandiegouniontribune.com/2019/11/17/parents-wait-for-answers-grieve-for-24-year-old-daughter/">Serna died</a> on the floor of her jail cell five days after she was booked into custody.</p><p>State medical regulators said Gilmore ignored Serna’s symptoms and should no longer be permitted to practice medicine.</p><div class="dfp-ad dfp-cube_article" id="div-gpt-ad-cube_article" style="visibility:hidden"> <div class="htlad-cube_article" data-unit="sandiegouniontribune.com/news/cube_article" data-targeting=""></div> </div><p>“Despite her knowledge and repeated notes indicating respondent was aware of patient A’s withdrawal from those substances, she simply provided absolutely no treatment for the withdrawals as required by the standard of care,” <a href="https://www2.mbc.ca.gov/PDL/document.aspx?path=%5cDIDOCS%5c20240816%5cDMRAAAJD16%5c&did=AAAJD240816214931423.DID&licenseType=C&licenseNumber=41580%20#page=1">the decision</a> says.</p><p>“Respondent also failed to provide any evaluation of Patient A with blood tests and EKG to evaluate her or provide any treatment plan for Patient A,” it adds. “As a direct result of those failures, Patient A died from a lack of treatment for withdrawal.”</p><p>Gilmore failed to appear at the hearing and offered no evidence to rebut or explain the accusation, the medical board decision dated Aug. 16 says.</p><p>The physician also was ordered to pay just under $30,000 toward the cost of the investigation.</p><p>Two jail healthcare providers were charged criminally in relation to Serna’s death, but Gilmore was not one of them.</p><p>Dr. Friederike Von Lintig and nurse Danalee Pascua <a href="https://www.sandiegouniontribune.com/2022/10/26/doctor-charged-in-womans-2019-jail-death-accused-of-neglecting-her-when-critically-ill/">were each charged</a> with a single count of involuntary manslaughter in the aftermath of the death, which was recorded on graphic surveillance video and presented in court as part of the criminal case.</p><p>A Superior Court jury acquitted Pascua and could not reach a verdict against Von Lintig. Prosecutors <a href="https://www.sandiegouniontribune.com/2024/02/14/after-jury-deadlocks-prosecutors-dismiss-case-against-doctor-accused-in-womans-jail-death/">declined</a> to refile charges against the doctor and dismissed the case.</p><p>The medical board <a href="https://www2.mbc.ca.gov/PDL/document.aspx?path=%5cDIDOCS%5c20230707%5cDMRAAAJD1%5c&did=AAAJD230707201224672.DID&licenseType=A&licenseNumber=84284%20#page=1">suspended Von Lintig</a>‘s license; state nursing regulators <a href="https://search.dca.ca.gov/details/4009/PHN/552854/777c0f3ea9dda36868d9f2c7098efc15">filed an accusation</a> against Pascua, but her license remains valid for now, records show.</p><p>Even though Gilmore was not charged by the District Attorney’s Office, the state medical board saw her actions as detrimental to Serna’s well-being. They began investigating and last year filed what’s called an accusation against her.</p><p>The decision released publicly this week did not surprise Paloma Serna, Elisa’s mother.</p><p>“Dr. Carol Gilmore had multiple chances to prevent Elisa’s tragic end, as did every other person who interacted with her,” Serna said by email Friday.</p><p>“It was within Gilmore’s responsibility to initiate the necessary protocols for alcohol and drug withdrawal,” she added. “Elisa suffered a painful death that could have been avoided. A simple call to 911 or arranging her transfer to a hospital could have made a difference.”</p><p>Paloma Serna also said: “My family and I find solace in the fact that Carol Gilmore will no longer be in a position to cause harm or loss of life.”</p><p>Elisa Serna was 25 years old and five weeks pregnant when she died. <a href="https://www.sandiegouniontribune.com/2020/04/13/parents-seek-answers-in-death-of-their-daughter-the-15th-inmate-to-die-in-san-diego-county-custody-last-year/">Medical records</a> from the five days she spent in custody before she died in custody show that neither deputies, nurses or doctors properly responded to her symptoms.</p><p>She was the 15th person to die in San Diego County jail in 2019.</p><p>More than <a href="https://www.sdsheriff.gov/resources/transparency-reports">70 other people have died</a> in Sheriff’s Department custody in the years since, making San Diego County one of the deadliest local jail systems in the state.</p></p> <div class="time mng-originally-published">Originally Published: <time datetime="2024-08-24 05:00:12">August 24, 2024 at 5:00 AM PDT</time></div></div></div><div class="article-bottom-share"><div class="article-share" id="sharing-bottom" ><div class="sharedaddy sd-sharing-enabled"><div class="robots-nocontent sd-block sd-social sd-social-icon sd-sharing"><h3 class="sd-title">Share this:</h3><div class="sd-content"><ul><li class="share-twitter"><a rel="nofollow noopener noreferrer" data-shared="sharing-twitter-8637772" class="share-twitter sd-button share-icon no-text" href="https://www.sandiegouniontribune.com/2024/08/24/doctor-involved-in-elisa-serna-jail-death-loses-medical-license/?share=twitter" target="_blank" title="Click to share on Twitter" ><span></span><span class="sharing-screen-reader-text">Click to share on Twitter (Opens in new window)</span></a></li><li class="share-facebook"><a rel="nofollow noopener noreferrer" data-shared="sharing-facebook-8637772" class="share-facebook sd-button share-icon no-text" href="https://www.sandiegouniontribune.com/2024/08/24/doctor-involved-in-elisa-serna-jail-death-loses-medical-license/?share=facebook" target="_blank" title="Click to share on Facebook" ><span></span><span class="sharing-screen-reader-text">Click to share on Facebook (Opens in new window)</span></a></li><li class="share-print"><a rel="nofollow noopener noreferrer" data-shared="" class="share-print sd-button share-icon no-text" href="https://www.sandiegouniontribune.com/2024/08/24/doctor-involved-in-elisa-serna-jail-death-loses-medical-license/#print" target="_blank" title="Click to print" ><span></span><span class="sharing-screen-reader-text">Click to print (Opens in new window)</span></a></li><li class="share-email"><a rel="nofollow noopener noreferrer" data-shared="" class="share-email sd-button share-icon no-text" href="mailto:?subject=%5BShared%20Post%5D%20Doctor%20involved%20in%20Elisa%20Serna%20jail%20death%20loses%20medical%20license&body=https%3A%2F%2Fwww.sandiegouniontribune.com%2F2024%2F08%2F24%2Fdoctor-involved-in-elisa-serna-jail-death-loses-medical-license%2F&share=email" target="_blank" title="Click to email a link to a friend" data-email-share-error-title="Do you have email set up?" data-email-share-error-text="If you're having problems sharing via email, you might not have email set up for your browser. 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