SANTEE, Calif. — A doctor accused of involuntary manslaughter will face trial later this month for her alleged involvement in the 2019 death of a woman detained in Santee's Las Colinas jail. But state medical officials have already filed the legal paperwork to have the doctor's license revoked or suspended based on the agency's own investigation.
According to the accusation filed by the Medical Board of California, Dr. Friederike Von Lintig was grossly negligent on multiple occasions to Elisa Serna, a 24-year-old mother who was pregnant and experiencing heroin withdrawal before she died. Serna was in Von Lintig's care the final day she was alive.
What happened to Elisa Serna?
While the accusation only refers to Patient A, the allegations and timeline matches up with the final days Serna was alive.
Serna was booked into Las Colinas November 6, 2019. She admitted to regular use of heroin, alcohol and Xanax. Her last use was two hours before she was booked, the accusation reads. Serna also took a pregnancy test on-site that had positive results.
She was in withdrawal and showing symptoms, but was not placed under the jail's withdrawal protocol. According to the accusation, Serna was instead placed in general housing where multiple people — both patients and staff — saw her vomiting regularly.
The Medical Board of California is also looking to revoke the license of Dr. Carol Gilmore, the doctor who first saw Serna.
Gilmore is also accused of negligence, according to the accusation.
"Dr. C.G. obtained Patient A's blood pressure, temperature and pulse, but otherwise did not conduct a physical examination at that time or thereafter," the document reads.
Von Lintig did not see Serna until November 11, 2019 when Serna was seen for frequent vomiting, dehydration and alleged "fainting spells" that medical staff believed she was faking. The accusation says Von Lintig "committed repeated negligent acts in her care and treatment of Patient A."
The medical board claims Von Lintig didn't check Serna's vitals and also incorrectly reported that Serna had finished withdrawal treatment.
"Respondent did not at any time, or any time thereafter, refer to 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, uninalysis, or electrocardiogram, and did not order IV fluids," the accusation reads.
Despite the symptoms of drug withdrawal, dehydration, and vomiting, the accusation states Serna was transferred back to general housing. While she was in a wheelchair outside of her isolation cell, it says Serna's body suddenly became stiff. She was not verbally responsive and her pupils were dilated.
"Patient A was placed back into her cell onto a mattress on the floor, given oxygen, and an urgent call for medical personnel was initiated."
Both Gilmore and Von Lintig saw her minutes later and Von Lintig took over Serna's care again.
She noted Serna's hands and feet were "very cold," according to the accusation. Von Lintig also said Serna had "normal" vital signs but did not document any vital signs in her chart.
"Respondent's assessment was that Patient A had not experienced a "true seizure," but she was unable to exclude a medical cause for the patient's weakness and fainting spells," according to the accusation.
Serna had a similar episode roughly two hours later. A deputy and a nurse soon came and placed her on a mattress on the floor.
The accusation states Von Lintig watched Serna through a video monitor but never returned to evaluate her.
Serna was dead less than five hours later. She died as a result of complications of "polysubstance abuse with early intrauterine pregnancy," the report reads.
Elisa Serna was one of 16 in-custody deaths during 2019
In 2022, the California State Auditor released a scathing report that said the San Diego County Sheriff's Department has a record of unusually frequent jail-inmate deaths in the seven detention facilities it oversees.
State auditors criticized the department for its handling of inmate deaths, saying 185 people died between 2006 and 2020, one of the highest totals among counties statewide.
Serna was one of 16 in-custody deaths during 2019.
The audit flagged the department's "underlying systemic issues" were cause for concern.
"In fact, our review identified deficiencies with how the sheriff's department provides care for and protects incarcerated individuals (that) likely contributed to in-custody deaths...In light of the ongoing risk to inmate safety, the sheriff's department's inadequate response to deaths and the lack of effective independent oversight, we believe that the legislature must take action to ensure that the sheriff's department implements meaningful changes," the document reads.
In 2023, Sheriff Kelly Martinez told CBS 8 the department has already implemented most of the recommendations in that audit, including improving screening procedures at intake, tracking inmate's healthcare, and confiscating drugs.
What's next?
Von Lintig's criminal trial on this case begins January 17 and will be heard in the east county courthouse.
The accusation filed by the Medical Board of California is a civil matter, meaning the criminal charges she's facing for involuntary manslaughter later this month is a separate manner. It is unknown when the board will make a ruling on the petition to revoke her license, but it has been suspended since July 2023.
This trial begins just shortly after another family is taking legal action against San Diego County and the Sheriff's Department claiming jail guards refused to perform CPR on the 25-year-old woman for 12 minutes as she lay dying. At the time of her death, Vianna Granillo struggled with addiction and allegedly had informed jail staff that she was suffering from withdrawals.
Von Lintig could not be reached for comment before her trial.
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