The case, set to go to trial in state court in St. Louis on March 17, centers on the 2020 death of LeQuon Marquis Vernor, who suffered from severe obstructive sleep apnea and relied on a Lincare-supplied BiPAP machine to help him breathe while sleeping. The lawsuit, filed by his mother, accuses Lincare of negligence after the company took seven days to respond to her report that the device had stopped working.

Lincare, the largest oxygen-device supplier in the U.S., with $2.4 billion in annual revenue, has long faced an array of legal issues, but it’s rare for a claim of wrongful death linked to its service and equipment to go to trial. The litigation over what happened to Vernor offers an unusual window into the company’s interaction with a vulnerable patient. This account is based on extensive court filings, including medical records, deposition excerpts and Lincare’s internal “customer account notes.”

Vernor lived with his mother, who was 64 and on disability, in a tidy public housing apartment complex in Madison, Illinois, across the Mississippi River from St. Louis. He suffered from obstructive sleep apnea, a common problem among adults with Down syndrome that is often exacerbated by obesity. Just under 5 feet tall, Vernor weighed 280 pounds.

Since 2015, Vernor had relied on a BiPAP (or bilevel positive airway pressure) machine, which delivers pressurized air through a mask. The device was prescribed after the Sleep Medicine Center at Washington University in St. Louis found that he repeatedly stopped breathing while he slept. “His airway is extremely crowded,” his doctor wrote in his medical notes at the time. Vernor, who was on Medicare, regularly used the device for 10 to 12 hours while he slept, according to his mother.

He spent his days at New Opportunities, a local nonprofit that provides educational opportunities for people with developmental disabilities. “He was a happy young man,” said Kim Fears, executive director of the program.

On Sept. 11, 2020, Vernor’s BiPAP suddenly started making “a loud buzzing or humming sound,” according to his mother, Sharon Vernor. She called the local Lincare office to report the problem, telling the customer service representative that the breathing machine wasn’t working and that it was “something that he needed” and “could not go without.”

The Lincare representative told her that, because his machine was more than 5 years old, under Medicare rules her son was eligible for a replacement BiPAP but that Lincare would first need to obtain a new order from his doctor. This was required for Lincare to collect rental payments for the new device. The representative later recounted making a call that day to the doctor’s office that went unanswered, then faxing the office a request. (Lincare said it was unable to find a copy of the fax among its voluminous records related to LeQuon Vernor.)

In the meantime, the representative suggested unplugging the malfunctioning BiPAP for 30 minutes. That didn’t fix the problem. The representative then promised, according to the account notes, to have a company respiratory therapist contact Sharon Vernor about the problem “until we get him a new machine.”

But that never happened. No one from Lincare, which had an office about 20 minutes away, came out to fix the broken machine or assess LeQuon Vernor’s condition, according to testimony in the case. (Lincare hadn’t performed any home visits or maintenance on the BiPAP since 2015.) As the company acknowledges, Lincare also never offered to provide Vernor with a “loaner” BiPAP to use while waiting for a new device to arrive. Industry veterans say other companies commonly provide temporary replacements while a patient with a malfunctioning device waits for a repair or a new, permanent one to arrive.

Without his BiPAP, Vernor struggled to sleep (and breathe), snoring loudly throughout the night. The Vernors got no further word from the company until seven days later, on Friday, Sept. 18.

Late that morning, Lincare nurse Ann Marie Eberle called Vernor’s mother, explaining that she would be arriving later that day with his new BiPAP. The doctor’s order had finally arrived. Sharon Vernor prepared a breakfast of sausage and biscuits for her son, who hadn’t yet gotten up. She was surprised when he still didn’t appear; the smell of food usually roused him. About 2 p.m., she went upstairs to wake him up.

She opened the door to find her son motionless in bed, with bloody fluid and foam coming out of his mouth and nose. His body was cold. The broken BiPAP sat on the dresser nearby. Frantic, she called 911. “I think my son’s dead! Oh Lord, please God, NO!” she screamed. “Please hurry!”

An ambulance and police cars were still parked in front of the Vernors’ apartment when Lincare’s Eberle pulled up to deliver the new BiPAP machine. “It just gave you a sunken feeling when you saw that,” Eberle later testified. Sharon Vernor met her at the door in tears. Eberle’s notes state that she “SAT WITH MOTHER UNTIL FAMILY MEMBER ARRIVED. POLICE STILL PRESENT UNTIL CORONER ARRIVED WHEN I LEFT.”

An autopsy completed two days later for the Madison County coroner found LeQuon Vernor’s lungs were a “maroon” color, heavily “congested and edematous” — filled with fluid that made it difficult to breathe. The report attributed Vernor’s death to “complications of obstructive sleep apnea.”

In 2022, Sharon Vernor brought a wrongful death suit against Lincare and Washington University, now set for trial next week. Her case accuses Lincare of putting profits ahead of patient care by failing to make sure that her son got a replacement BiPAP quickly and refusing to provide “loaner equipment” in the meantime, because the company didn’t believe it could bill for it.

“In short, when faced with information that LeQuon’s bipap was not working properly, Lincare did nothing,” a December 2024 filing alleged. The company took no action for a week, even though “Lincare knew this was a life-or-death situation for their customer LeQuon.” Johnny Simon, the Vernors’ St. Louis lawyer, said that “this was an avoidable, horrific tragedy.” (Sharon Vernor declined an interview request.)

The suit also accuses the Washington University medical program of failing to respond “in a timely manner” to requests for a new BiPAP order. The clinic’s prescription for LeQuon Vernor’s new BiPAP was signed on Sept. 15 but not sent back to Lincare for two more days. The Washington University medical school declined comment through a spokesperson, citing the litigation. In a legal filing, the university denied the allegations in the suit.

ProPublica has reported extensively on Lincare, which has a decadeslong history of Medicare-related misconduct, including multiple settlements regarding claims of billing fraud. And that misconduct continued even while the company was under government “probationary” agreements requiring it to provide enhanced compliance oversight. On the Better Business Bureau’s website, 939 customer reviews give the company an average 1.28 rating out of 5, offering lacerating complaints about dirty and broken equipment, delivery delays, nightmarish customer service, improper billings, and harassing sales and collection calls.

In emailed responses to questions from ProPublica, Lincare offered its “sympathies” to the Vernor family but asserted that “the allegations against Lincare are false.” The company said that it is legally barred from providing even a loaner BiPAP until it receives a new prescription and suggested that it had no reason to believe LeQuon Vernor faced a life-threatening situation, because “a BiPAP is not a life-sustaining device.” The company added: “Lincare delivers a high level of care to millions of patients in a heavily regulated field. Our response to this case was consistent with legal requirements and our policies.”

Lincare’s lawyers went a step further in a February court filing, blaming what happened on an alleged failure by Vernor’s doctors to provide the new order promptly. “Lincare did its job,” the company argued. “The moment Lincare knew that Decedent needed a new machine, Lincare reached out to Decedent’s medical provider. However, Lincare did not receive an updated prescription until one week later.” The company, they added, was “at the mercy of Decedent’s medical provider to supply an updated prescription.”

Sharon Vernor’s lawyers dispute Lincare’s claim that it was barred from providing a loaner BiPAP without obtaining a new prescription. (A spokesperson for the Centers for Medicare and Medicaid Services declined to address the issue, citing a “pause on mass communications and public appearances” imposed by the new Trump administration.) LeQuon Vernor’s 2015 prescription, filled by Lincare, also specified that he had a “lifetime” need for a BiPAP.

Two former Lincare managers told ProPublica that they were discouraged from dispatching temporary replacement equipment; at least one manager instructed staff to falsely tell customers “all our loaners are out.” One said that, acting on orders from her supervisor, she tossed CPAP and BiPAP devices marked by local offices as loaners into dumpsters. The respiratory companies they later worked for, both said, routinely provided loaner equipment to patients who relied on a breathing device while they awaited a repair or a doctor’s order required to replace it. As one of them put it, “We would make sure the patient is taken care of in that moment.” (“Lincare’s policy is to provide loaner equipment to its patients in accordance with our patient care standards and regulatory requirements,” the company responded.)

In a deposition, Dr. Gabriela de Bruin, a Washington University neurologist who assessed Vernor’s sleep study in 2015, said allowing him to go a week without a functioning BiPAP posed a serious health risk, given the severity of his disease. Noting that Vernor had “severe sleep apnea,” she said, “Anytime we prescribe treatment for obstructive sleep apnea, our recommendation is that patients should use it nightly and should avoid being without their device if they can.” Asked whether Lincare should have understood that Vernor’s apnea created a risk of death, she said, “It’s very difficult for me to say there was this much risk that he could have died.” She added, “But certainly, I would be very concerned.”

A judge in the case dealt Lincare a setback on March 5, ruling that the evidence presented by Sharon Vernor’s lawyers had met the state’s legal standard for seeking punitive damages. That, he wrote, would allow a “trier of fact” to reasonably conclude that “Lincare intentionally acted with a deliberate and flagrant disregard for the safety of others.”

During deposition questioning, Pamela Karban, the manager of the Lincare outlet that handled LeQuon Vernor’s equipment, testified that “we should have referred the mom, if it was that serious, to take him to the nearest emergency room.” Asked whether the company was negligent for not providing Vernor with loaner equipment, she replied: “Yes. We failed to provide that.” Lincare subsequently submitted an affidavit, signed by Karban, stating that she didn’t understand the legal meaning of the term “negligence.”