Witnesses saw her stumbling around her cell, wobbly and falling down. She was vomiting repeatedly, and repeatedly knocked on the door or pressed the call button, seeking help.
Some of the time, sheriff’s deputies and jail medical staff responded. Other times they ignored her, or peeked momentarily through the small window in the cell door as they ed.
The doctor on call thought Elisa Serna was faking.
Thousands of pages of witness interviews, videos and other evidence unsealed this past week under a federal court order show in excruciating detail how desperate and tragic Serna’s last hours were.
“She sits for a moment the(n) tries to crawl to her bed,” wrote Dr. Homer Venters, an expert in correctional health care hired by Serna’s legal team to evaluate internal San Diego County jail evidence, in a now-public report.
“She is on her hands and knees. She is obviously unstable in this position. She can be seen wobbling. She takes a moment to collect herself. She slowly stands up and walks to her bed. She tries to move to her bed, but she falls over.”
In her final hour of life, late on a Monday in November 2019, Serna was left alone to die, even though a deputy and nurse had just watched her collapse and strike her head as she fell to the floor.
When they returned nearly one hour later, she was lying, dead, in the same position in which they had left her.
Dozens of filings totaling thousands of pages were publicly released last week, after The San Diego Union-Tribune and CBS 8 News intervened in the civil lawsuit the Serna family filed against the county and jail medical providers.
Lawyers for San Diego County had spent years working to delay the civil litigation and keep key evidence sealed from public view — even after several of the videos and interview transcripts were presented in open court during criminal proceedings.
Jail nurse Danalee Pascua was charged with involuntary manslaughter but acquitted earlier this year. The jury deadlocked on the same charge against Dr. Friederike Von Lintig, and prosecutors declined to refile the case.
But the newly disclosed information reveals a much broader seeming indifference to the well-being and fate of people in Sheriff’s Department custody.
Not only did jail staff fail to implement their own drug-withdrawal protocols in treating Serna, they overlooked her apparent condition. They never called 911, and they withheld care because the doctor in charge thought she was pretending to be sick.
“Doctor Von Lintig did not express any reason as to why she thought Serna was faking her condition,” Deputy Lupita Cardenas told an internal affairs investigator, some of the unsealed documents show. The investigator added: “Deputy Cardenas said it is common for inmates to fake illness.”
Serna was 24 and pregnant when she was arrested on suspicion of theft and drug charges.
When she was booked into Las Colinas women’s jail, she told deputies that she had recently used drugs and alcohol, records show, and she was supposed to be placed into the sheriff’s withdrawal protocols. She was not.
Instead, she collapsed six days after her arrest and died, becoming the 15th person to die in a San Diego County jail in 2019. Sixty-seven more people have died in sheriff’s custody since Serna was found dead on the floor of her Las Colinas jail cell, records show.
Venters said in his unsealed report that evidence he viewed as part of the discovery process proves the sheriff’s jail medical staff failed completely.
“There is no more basic duty for a physician or other healthcare professional than to go assess a patient when they are ill or when told they need assistance,” the plaintiff’s expert witness said in his report.
“These individual failures also reflect the lack of effective management and oversight of the jail’s health service,” he said.
Sheriff Kelly Martinez issued a statement Thursday acknowledging the seriousness of the materials released under the judge’s order.
“The video and other evidence in this case is disturbing and the actions of some staff on that day do not reflect the values of the Sheriff’s Department,” she said. “Since becoming sheriff last year I have made substantial changes improving the conditions in our county jails.
“Those changes are ongoing and I am committed to seeing them through.”
Paloma Serna, Elisa’s mother and one of the plaintiffs suing San Diego County, said seeing the long-sealed evidence posted online was difficult for the family but needed.
“This is very saddening to watch the videos again,” she said. “But it is necessary for the public to see how badly the San Diego sheriff’s deputies and the medical staff ignored and neglected Elisa during her medical distress.”
In her statement Thursday, Martinez also cited a series of steps she has taken to reduce deaths in the jails, including upgrading facilities, enrolling hundreds of people with drug addictions in medication-assisted treatment and working to provide 24-hour mental health care.
Twenty people died in San Diego County jails in 2022 and 13 more last year. So far this year, four people have died in sheriff’s custody, department records show.
And the Union-Tribune reported last month that the sheriff’s primary health care provider has badly underachieved since it was hired two years ago to manage health care for the 4,000 or so people in county jails.
Among other deficiencies, NaphCare Correctional Health failed to pay outside hospitals, denied gynecological care to patients in custody and ignored repeated requests to repair and replace medical equipment, an internal report said.
“Contractor refused to pay for abortions, as they deemed it ‘elective,’” the Sheriff’s Department told NaphCare in a corrective action notice late last year.
Paloma Serna criticized the sheriff for saying she was fixing San Diego County jails as men and women continue to die behind bars.
“There have been four in-custody deaths this year, but Kelly stated she ‘made substantial changes improving the conditions’,” she said. “This is not true.”
The vast trove of evidence and other materials just unsealed includes jarring videos that show Elisa Serna struggling in her cell.
At various points, she can be seen stripping off her clothes, vomiting profusely and twisting and squirming across the medical isolation unit she had been placed in for her own protection.
The night Serna died, the video shows jail staff watching her fall, striking her head and tumbling to the floor. They closed the cell door as Serna lay motionless.
In an interview with an internal affairs investigator, Pascua said the collapse was not alarming.
“The fall didn’t really concern me just ‘cause she was sliding down the wall,” the nurse said. “I feel like if you really did out you would just fall; it didn’t matter how you fell. But I felt like she was slowing down her fall.
“So, um, we just left her sitting on the floor like that. So, I said, we will check on her again,” said Pascua, who grew emotional during her interview, investigators noted.
Other testimony showed that other incarcerated women who were assigned to clean up Serna’s cell had said they were overwhelmed by her appearance and condition.
One woman incarcerated with Serna before she was placed into isolation “noted her vomit was black and her skin was grayish,” one of the reports states.
Another said “it was not the cell that smelled bad, because there was no trash. It was Ms. Serna who smelled bad … Elisa Serna smelled like los muertos (the dead).”
The unsealed evidence also included the mortality report drafted by Dr. Jon Montgomery, the sheriff’s chief medical officer.
Montgomery concluded in a report almost two months after Serna died that county employees had failed badly in their duty. The four-page document lays out the timeline of events and specific deficiencies by staff, including ineffective medical treatment and poor documentation.
“Could medical response at the time have been improved? Yes. Video evidence confirms delay in rendering of care,” the report says.
The jail medical staff’s decision to return Serna to the jail’s general population was ill-advised, Montgomery concluded, and health care workers should have responded to the vomiting more effectively.
“Self-induced or not, the vomiting can lead to severe electrolyte and acid/base dysfunction,” he wrote. “Labs should have been obtained and consideration of send-out” to a nearby hospital.
In other portions of the newly released material, Venters said the sheriff’s mortality reviews are woefully inadequate. Internal records he reviewed showed deficiencies occurred time and again, leading to many people dying unnecessarily, he said.
The lack of proper postmortem evaluations denied Sheriff’s Department leaders the opportunity to learn from their mistakes and prevent deaths in custody, he said.
“There is no root cause analysis or review of the specific workflow errors that led to this failure, and consequently, no identification of how this error will be avoided or even tracked in future cases,” Venters found.
The Serna family lawsuit is proceeding in San Diego federal court. Absent any settlement, a trial is expected to begin sometime next year.
