NewsTeam 10 Investigates


Medical Board alleges doctor was negligent in pregnant woman’s jail death

Physician says she didn't do anything wrong
Elisa Serna
Posted at 4:26 PM, Oct 26, 2023
and last updated 2023-10-26 21:31:22-04

SAN DIEGO, Calif. — The Medical Board of California alleges a veteran physician failed to properly care for a pregnant inmate before she died behind bars in county jail.

The board says in a recently published accusation that Dr. Carol Ann Gilmore, 70, committed gross negligence in her care of Patient A, who ABC 10News has confirmed is Elisa Serna.

Serna, 24, died in 2019 at the Las Colinas Detention Facility in Santee.

“This poor woman died alone on the floor of her jail cell and never received, according to the medical board documents, adequate treatment for her withdrawal while she was pregnant,” said patient safety advocate Marian Hollingsworth.

Another doctor responsible for Serna’s care as well as a nurse have been criminally charged with involuntary manslaughter for their role in her death. Both have pleaded not guilty.

The medical board’s accusation said Gilmore, an Escondido physician, failed to properly manage Serna, who had been going through heroin and alcohol withdrawal.

Doctor surrenders license

It said on the day of Serna’s death she was seated in a wheelchair outside her cell when her body “suddenly stiffened with her head resting on the back of the chair and her legs dangling on the floor.”

Dr. Gilmore ordered Serna to have Ativan but didn’t speak with her or perform an exam, the medical board said.

Instead, the physician, who has been licensed since 1984, “stood by and watched” as another doctor evaluated the patient.

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Patient safety advocate Marian Hollingsworth says California doctors who surrender their medical licenses can apply to have them back in the future if they choose.

Later that night, Serna was found unresponsive and pronounced dead because of complications of substance abuse with early pregnancy.

Gilmore said, “I didn’t do anything wrong,” when reached by ABC 10News investigative reporter Austin Grabish Thursday.

She said she was called from her clinic to run over to Serna because Dr. Friederike Von Lintig, who’s since been charged with involuntary manslaughter, was outside smoking.

“I had to leave my naked patient to go over and deal with that.”

Gilmore said she wasn’t even with Serna for five minutes and said it was Von Lintig, who should’ve ordered tests on Serna.

Gilmore said after the medical board filed its accusation against her, she decided to surrender her medical license.

Asked if that was difficult, she said “It was liberating,” noting she is now 70 years old and retired.
Von Lintig and nurse Danalee Pascua, 38, will go to trial on involuntary manslaughter charges in Serna's death next year.