The mother of a 25-year-old man who was serving a 45-day sentence in Androscoggin County Jail for driving-related charges, including operating under the influence, has filed state and federal lawsuits against the jail and its for-profit contracted medical provider, Correctional Psychiatric Services, for his death from complications from lobar pneumonia after developing bed sores which became infected.
The federal Complaint filed on June 9, 2025 alleges, in part:
On October 25, 2023, Trevor reported to ACJ. He was expected to serve 45 days. Trevor had a history of a spinal cord stroke. His left-side mobility was limited, but he walked independently, occasionally with the assistance of a cane.
Trevor slept with braces on his left hand to prevent it from retracting. Left hand muscle retraction was a long-term effect of his stroke. Trevor’s stroke also gave him long-term urinary hesitancy and incontinence, which he could manage independently and without medical devices if he had access to a restroom.
Trevor reported his stroke and limited mobility to Androscoggin County Defendants, by and through ACJ Defendants, when he was booked at ACJ on October 25. ACJ Defendant Tammy Chase performed Trevor’s inmate classification on
October 25. He was placed in a cell in an ACJ minimum security block.
Trevor also reported his stroke and limited mobility to the ACJ medical department during a medical screening on October 25. The screening, which noted the nature of Trevor’s disability, became part of Trevor’s medical record at ACJ, which was accessible to all ACJ medical staff.
Early in Trevor’s sentence, Pam brought Trevor’s left hand braces to ACJ. Pursuant to an explicit or implicit ACJ policy, Trevor was not provided his braces. Without his left hand braces, Trevor struggled to use his left upper extremity and
hand. Trevor’s lack of his left hand braces made it more difficult for him to prevent, and then properly care for, the pressure ulcers he developed shortly after arriving at ACJ. The pressure ulcers caused open wounds, making Trevor at risk for developing infection.
On or before November 1, Trevor began developing pressure ulcers on his lower back and buttocks. On November 1, Trevor reported two wounds on his lower back and buttocks to the medical department. On November 2, Trevor told Pam that the ACJ medical staff did not understand the nature of his disability. Later that day, Pam called the ACJ medical department and offered to provide them with Trevor’s medical records so they could better understand his medical history. An ACJ medical staff member told Pam she could fax the records or drop them off in person.
Pam dropped off Trevor’s medical records at ACJ on November 2. She provided the records to ACJ Defendant John or Jane Doe, a corrections officer who was staffing the front desk. Neither Defendant John or Jane Doe or anyone else at ACJ provided Trevor’s medical records to the ACJ medical department; those records were therefore not reviewed by any of the ACJ medical staff.
On November 4, Trevor was seen by a nurse at ACJ. The nurse documented that Trevor had two wounds that had developed five days earlier. On November 4, a nurse practitioner prescribed rotating dressing changes to address Trevor’s wounds. On November 6, Trevor was seen by a nurse practitioner for a telehealth assessment. He reported his wounds to her, but she did not physically examine them.
On November 11, Trevor presented to the ACJ medical department, escorted by Corrections Officer Jane and/or John Doe(s). Trevor reported that his wounds were painful and that the pain worsened when they contacted any surface. On November 12, Trevor reported feeling very ill and that his entire body hurt.
On November 13, an ACJ nurse evaluated Trevor in the medical department. Trevor complained of chest and upper back pain. Trevor’s heart rate was abnormally high (tachycardic). He had diminished breath sounds in the base of his left lung.
A reasonable medical provider presented with a patient complaining of chest and upper back pain, accompanied by tachycardia and diminished breath sounds, must be concerned about the possibility of potentially severe, life-threatening illness, including heart attack, pneumonia and pulmonary embolism. Nevertheless, the nurse, without consulting a doctor, determined that Trevor was “demonstrably stable despite the stated symptoms.” The nurse suggested that Trevor was likely suffering from anxiety, despite the fact that rendering diagnoses is outside the scope of nursing practice and the patient’s symptoms were equally consistent with several more severe medical conditions that had not been adequately ruled out.
Because ACJ did not properly train or supervise its medical staff in the safe and proper use of the medical record to provide continuity of care, the nurse did not enter his November 13 note into the medical record. Therefore it was not available for review by other providers involved in Trevor’s medical care.
Consequently, ACJ medical staff who saw Trevor after November 13 were unaware of his report of chest pain. Despite the fact that chest pain is a common sign of a potential medical emergency—and despite the widespread availability and use of standardized “chest pain” protocols to ensure that life-threatening cardiac conditions are not missed—ACJ had no “chest pain” protocol or other policy that required a nurse to consult with ACJ medical department providers (nurse practitioners or physician assistants) or any other medical provider regarding patient chest pain.
Between November 13 and 15, Trevor rarely left his cell in minimum. Trevor, who was in visible distress and had lost his ability to support his own weight and walk independently, writhed in pain and moaned for help in his bed. ACJ Defendants and medical department staff ignored Trevor’s pleas. During that same time, ACJ Defendants also ignored the pleas of Trevor’s cellmate and block mates who alerted them repeatedly to Trevor’s rapidly declining condition.
On November 14, Trevor presented to a nurse in the ACJ medical department “ambulating slow & unsteady.” The nurse determined that Trevor’s wounds were worsening and had become a medical emergency. The nurse has testified that he contacted the on-call medical department provider, and that he and the on-call provider agreed that Trevor needed to be seen by a provider outside the jail. The nurse has also testified that Nurse Riebe refused to send Trevor outside the jail for medical attention.
Upon information and belief, Nurse Riebe’s refusal to send Trevor outside the jail for medical attention was the result of an ACJ custom and practice that discouraged providing inmates with care from outside medical providers as a cost-saving measure.
On November 15, Trevor was moved from his cell in minimum to OB-3, a cell in ACJ’s “observation” or “holding” block. Corrections Officers Jane and/or John Doe(s) moved Trevor in a wheelchair because he could no longer walk on his own.
Inmates in the observation block are supposed to be monitored continuously by ACJ Defendants via video and audio surveillance, observable from the “Control Room” located across the hall from OB-3. Inmates in observation are also supposed to be monitored by ACJ Defendants who round on the cells every 15 minutes. During these rounds, ACJ Defendants are supposed to inspect the physical cell to ensure its safety, check the that the inmate is “living” and “breathing,” and check the inmate’s “flesh,” meaning their general appearance.
The observation cells have no toilets or sinks. Instead, ACJ Defendants expect inmates to alert them when they need to use the bathroom; alternatively, inmates are forced to urinate or defecate into a grate on the cell floor.
On November 15, Trevor was evaluated by an ACJ physician assistant in the presence of Corrections Officer Jane and/or John Doe(s). This medical appointment took place in Trevor’s observation cell because he could not walk to the ACJ medical department. Later on November 15, Corrections Officers Jane and/or John Doe(s) moved Trevor via wheelchair to ACJ’s maximum security block.
The physician assistant determined that Trevor could be suffering from rhabdomyolysis, a life-threatening condition where damaged muscles release toxins into the bloodstream, or sepsis, an inflammatory response to infection that leads to organ failure and death if not treated promptly. Nevertheless, the physician assistant did not take any steps to provide Trevor with emergency medical care.
The physician assistant’s failure to recommend that Trevor be sent to an outside provider for emergent care was the result of an ACJ custom and practice of discouraging staff from sending inmates for outside medical care because of the high cost of doing so.
The physician assistant’s failure to recommend that Trevor be sent to an outside provider for emergent care was also the result of an ACJ custom and practice of failing to train medical staff on and enforce the proper use of the electronic medical record.
Inmates in maximum are supposed to be monitored by ACJ Defendants through “living, breathing, flesh checks” every 15 minutes. Throughout the day on November 16, Trevor was too sick to get up and move about. He remained lying on his back in his cell. The ACJ Defendants knew that it was dangerous and painful for Trevor to remain lying on his back due to his pressure ulcers. ACJ Defendants also knew that Trevor was too weak to sit up, move or reposition himself.
The bed in OB-3 is a cement slab raised just inches off the floor, with a plastic mattress placed on top of it. ACJ Defendants took no steps to move Trevor off his back to relieve pressure or to otherwise provide him with life-saving medical attention.
On November 16, wound care was performed in Trevor’s cell in the presence of Corrections Officer Jane and/or John Doe(s), because Trevor could not walk to the medical department.
On November 17, at 8:20 am, Trevor fell off his bed and hit his head on a desk. This was further evidence of his deterioration. Although aware of Trevor’s fall, ACJ Defendants took no steps to get him emergency medical care.
Shortly after his fall, Trevor was moved via wheelchair back to observation cell OB-3 by ACJ Defendants Rebecca Leduc, Bryan Litchfield, Reginald Littlefield, and Isaac Poliquin. Trevor was weak and nodding off in his wheelchair. Corrections Officers Litchfield and Poliquin lifted Trevor from the wheelchair by his elbows and placed him on his side on the bed slab in OB-3.
Before ACJ Defendants Leduc, Litchfield, Littlefield, and Poliquin left OB-3, Trevor was lying on his back, as he was physically unable to remain on his side. Nonetheless, ACJ Defendants took no steps to reasonably ensure that Trevor was properly positioned with pressure removed from his wounds.
ACJ Defendants Leduc, Litchfield, Littlefield, Poliquin, and those monitoring Trevor by video, observed his rapidly declining condition, but remained deliberately indifferent to his imminent risk of severe harm or death, and took no steps to provide Trevor with emergency medical care.
During his stay in OB-3, Trevor was so weak that he urinated on himself repeatedly while lying on his back.
ACJ Defendants witnessed Trevor urinating on himself via video surveillance and during “living, breathing, flesh checks.” It was objectively obvious that Trevor was continuing to decompensate physically and that he needed emergency medical care. Nonetheless, ACJ Defendants took no steps to facilitate such care.
Around 9:00 am on November 17, Corrections Officer Poliquin accompanied a nurse into Trevor’s cell for a routine medication pass. Corrections Officer Poliquin observed that Trevor was unable to hold a cup of water or sit up to take his medicine. Corrections Officer Poliquin grabbed Trevor by his uniform shirt to sit him upright. Corrections Officer Poliquin also observed that Trevor had urinated on the floor next to his bed slab.
On November 17, Corrections Officer Litchfield and a nurse entered OB-3. Trevor told them that he could not move. Corrections Officer Litchfield grabbed Trevor’s jail uniform and rolled him over to his side, so that the nurse could change the dressing on his wounds. It was objectively obvious that Trevor was extremely ill and required emergency medical treatment. ACJ Defendants continued to perform “living, breathing, flesh checks” on Trevor every 15 minutes, thereby observing his decline.
Throughout his stay in OB-3, Trevor continued lying supine. He continued urinating from that position while lying on his bed slab. Urine visibly pooled on the floor of his cell. The wounds were dark, odorous and obviously infected. It was obvious to Corrections Officer Litchfield, the ACJ nurse and the ACJ Defendants monitoring Trevor that his health was declining rapidly and he needed emergency medical care. Nonetheless, they took no steps to facilitate such care.
During the evening of November 17, ACJ Defendants John Clevenger and John Doe entered OB-3 with an ACJ nurse for a medication pass. The ACJ Defendants and nurse watched Trevor, who was unable to sit up, attempt to pour Gatorade into his mouth while lying on his back. Trevor could not take his medication without assistance.
On November 18, Trevor was provided food by ACJ Defendant John Doe. He was not able to eat it, and the full tray was later collected by Corrections Officer Leduc. Corrections Officer Leduc returned some hours later, accompanied by a nurse who was distributing medication. Corrections Officer Leduc attempted to hand Trevor a cup of water, which he could not hold. She attempted to prop Trevor upright, but he could not sit up, so he fell back onto the bed. Corrections Officer Leduc placed the medication in Trevor’s mouth and poured water into his mouth while he was lying supine. Trevor remained on his back throughout the visit and when Corrections Officer Leduc left his cell.
On the afternoon of November 18, ACJ Defendants Victoria Langelier, Larocque, and Leduc went to Trevor’s holding cell to move him to maximum. Trevor told them he was unable to sit up on his own. After the officers sat him up, they told Trevor that he needed to help them by standing on his feet. Trevor told them he could not do so. The officers lifted Trevor and placed him in a wheelchair, which they used to transport him to his new cell.
When they arrived at maximum, Corrections Officer Larocque instructed Trevor to get out of the wheelchair and walk into his cell. Trevor could not do so. Officer Larocque attempted to pull Trevor to his feet. Trevor could not stand, and fell to his knees. Corrections Officer Larocque lifted Trevor under the arms and dragged him into his cell. While they were retrieving Trevor, Corrections Officer V. Langelier noticed that the floor was covered in urine.
While he was being transported to maximum, Trevor was wheeled past Corrections Officer Chase and ACJ Defendant James Langelier. They then assisted in his transport. Corrections Officers Chase, J. Langelier, and V. Langelier watched this interaction take place.
At or around 4:36 pm, Corrections Officer Chase left a tray of food next to Trevor’s bed. Approximately twenty minutes later, Corrections Officers Chase and J. Langelier returned to collect the tray. They observed that Trevor did not eat any of the food on his tray and was “slow to move.”
Throughout this time, it was objectively obvious to ACJ Defendants that Trevor’s health was declining rapidly, and that he needed emergency care. Nonetheless, they took no steps to facilitate such care.
On November 18, at 6:48 pm, ACJ Defendants Paul Hamann, Miranda Kologenski, and John Doe began performing the “living, breathing, flesh checks” in maximum every 15 minutes. At 8:00 pm, Corrections Officers Hamann, Kologenski, and John Doe escorted a nurse to Trevor’s cell for a medical check. They found Trevor unresponsive on his bed. At 8:40 pm, Trevor was pronounced dead.
At 10:00 pm on November 18, Pam was notified of Trevor’s death. Later that evening, Pam spoke with ACJ Defendant William Gagne, who was aware of Trevor’s decline during his incarceration, regarding the circumstances of Trevor’s death. When Pam asked Chief Deputy Gagne how Trevor had died, he lied or actively misled her, stating that Trevor’s cause of death “could have been something as simple as choking on coffee.”
On November 19, an autopsy was performed. Trevor’s cause of death was determined to be lobar pneumonia. The autopsy report stated: “On the back is a padded gauze covering overlying the sacrum. This covers a stage 3 pressure ulcer with necrotic tissue present.” It also revealed bilateral empyema in Trevor’s lungs, with “multiple scattered abscesses in the parenchyma.” Trevor’s pneumonia was the result of his untreated, infected pressure ulcers.
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