State v. Kinsella

578 S.W.3d 802

STATE of Missouri, Respondent,

v.Rachel A. KINSELLA, Appellant.

No. ED 105655

Missouri Court of Appeals, Eastern District, DIVISION THREE.

Filed: March 5, 2019

Jedd C. Schneider, 1000 West Nifong, Bldg. 7, Ste. 100, Columbia, MO 65203, for appellant.

Eric S. Schmitt, Atty. Gen., Garrick Aplin, Asst. Atty. Gen., P.O. Box 899, Jefferson City, MO 65102, for respondent.

LAWRENCE E. MOONEY, JUDGE

We recount an assault that is difficult to comprehend. The defendant, Rachel A. Kinsella, is a knowledgeable, medically-savvy mother. The victim is her medically-challenged young son, P.K. Over a nine-month period, defendant took her son to two different teams of doctors – one in Kansas City, the other in St. Louis. But due to the defendant’s deceptions, the teams of doctors did not know of each other’s existence. Thus, each team prescribed different anti-psychotic and anti-seizure medications fraught with severe, debilitating, even life-threatening consequences. Defendant’s conduct brought P.K. to the brink of death.

After a three-day trial, a jury found defendant guilty of first-degree assault and first-degree endangering the welfare of a child, for poisoning her son, P.K. Defendant now appeals, alleging insufficient evidence existed that she acted "knowingly" or "intentionally." She contends the jury engaged in impermissible inference-stacking in convicting her. To the contrary, we find no attenuated logic. Sufficient evidence exists to reasonably infer that defendant acted knowingly and intentionally. We therefore affirm defendant’s convictions.

Factual and Procedural Background

P.K.’s Early Years

P.K. was born prematurely in August of 2005. Around the time of his birth, he suffered a bleed in his brain that required the placement of a shunt to drain fluid off his brain, in order to reduce the pressure on his brain. At other times in his young life, doctors also variously diagnosed P.K. with epilepsy, attention deficit hyperactivity disorder (ADHD), cognitive disorder, autism spectrum disorder, Asperger’s syndrome,¹ bipolar disorder, and as having a cerebrovascular accident. P.K.’s parents divorced in 2010. Two years later, in August of 2012, P.K.’s father died. P.K. was seven years old.

Treatment Begins in Kansas City

A week and a half after the death of P.K.’s father, defendant took P.K. to see Dr. Shayla Sullivant, a child psychiatrist at Children’s Mercy Hospital in Kansas City. This was P.K.’s first visit with Dr. Sullivant. In addition to corroborating the ADHD and cognitive-disorder diagnoses, Dr. Sullivant also diagnosed P.K. as having "adjustment disorder with depressed mood." Dr. Sullivant prescribed Risperdal, an anti-psychotic medication, and physicians in the neurology department at Children’s Mercy prescribed Trileptal, an anti-seizure medication. Risperdal and Trileptal are the drugs with which defendant was alleged to have poisoned P.K. Dr. Sullivant reviewed the benefits and risks of the medications with the defendant. Dr. Sullivant specifically told defendant that Risperdal could lower the seizure threshold for P.K.

Defendant brought P.K. to see Dr. Sullivant three additional times during 2012, the last time being in November. Despite Dr. Sullivant wanting to see P.K. every eight weeks, defendant did not bring P.K. in for another visit until July 2013. During that eight-month time period, defendant repeatedly requested refills for the Risperdal, Dr. Sullivant initially approved those refills, but ultimately told defendant that she would only approve the Risperdal refill if defendant brought P.K. in for a visit, which finally occurred on July 26, 2013. Dr. Sullivant saw P.K. again in September, the last time she would see P.K. in 2013. Defendant canceled an appointment in November, and was a no-show at another appointment. When asked why, defendant told staff at Children's Mercy that she intended to seek treatment from a psychiatrist in St. Louis.

Despite this stated intent, defendant in February of 2014 again asked Dr. Sullivant for a refill of P.K.’s medications. Dr. Sullivant denied the request because P.K. was not scheduled for another visit at Children’s Mercy. Dr. Sullivant was also concerned that defendant may have found another provider for P.K.’s care. Defendant denied that anyone else was prescribing medication for P.K. and stated that she was transferring all of P.K.’s care back to Children’s Mercy. Defendant scheduled an appointment with Dr. Sullivant, for March 4, 2014. Given this, Dr. Sullivant authorized a refill of P.K.’s medications. Defendant brought P.K. in for the March 4th visit, but did not schedule a follow-up visit with the doctor, as instructed. Defendant did not bring P.K. to see Dr. Sullivant until nine months later, in December of 2014. During that ninth-month time period, defendant repeatedly requested and received refills for Risperdal and Trileptal from the doctors in Kansas City. During this same nine-month period, P.K. also received extensive medical treatment from doctors at St. Louis Children’s Hospital.

St. Louis Hospitalization and Beginning of Treatment in St. Louis

On March 7, 2014, three days after his visit with Dr. Sullivant, P.K, was life-flighted to St. Louis Children’s Hospital after a reported prolonged seizure. When P.K. arrived at the hospital, he was extremely unresponsive. Medical staff could not awaken P.K., even by pinching him or rubbing his sternum – measures used by medical personnel to awaken unresponsive patients. If he did awaken, it was only briefly and then he would fall back asleep. These prolonged, sudden spells of extreme unresponsiveness continued, on and off, for the next two months while P.K. was in the hospital. P.K. also had hallucinations and nystagmus.² He drooled and exhibited inappropriate emotional responses. He was also very unsteady, and often had trouble walking and with coordination. When asked to touch his nose or touch an object in front of him, P.K. would often miss. At other times, however, P.K. would appear normal, and was observed talking and playing video games. His periods of unresponsiveness were episodic, not continuous. His symptoms would wax and wane.

The St. Louis physicians ruled out an exacerbation of P.K.’s underlying illnesses. Tests also showed that P.K.’s shunt was functioning property, and that the pressures inside his brain were within the normal range. And although defendant reported that P.K. had seizures, extensive monitoring showed no evidence of seizure activity. The doctors concluded that P.K.’s spells and periods of unresponsiveness were not seizures. They began considering other diagnoses, including that P.K. may have been experiencing an autoimmune disease affecting his brain. Tests came back weakly positive for such a disease, so the St. Louis physicians settled on a diagnosis of autoimmune encephalitis (AE) and began aggressively treating P.K. for that disease. Although monitoring did not show seizure activity, the St. Louis physicians could not completely rule out the possibility that P.K. was having undetected seizures. So they changed P.K.’s medications. The St. Louis physicians discontinued the use of Risperdal at the end of March 2014, and replaced it with a similar anti-psychotic medication called Seroquel, which they believed would be a better drug for P.K. They discontinued the use of Trileptal at the beginning of April 2014, and replaced it with a broader-spectmm seizure medication called Clobazam.

The physicians in St. Louis had multiple discussions with defendant regarding the treatment plan for P.K. This included daily rounds, when physicians would visit P.K., review his progress, his lab results, and discuss the plan of care for the day. Defendant was frequently present with P.K., and sometimes slept at the hospital. Defendant told the St. Louis physicians that she was glad P.K. was receiving his care at St. Louis Children’s Hospital, and that she was transferring care of P.K. to St. Louis from Kansas City. Defendant also told the St. Louis physicians that she was glad they discontinued the Trileptal because she never thought it very effective. Despite her representation that she was transferring care, and her awareness that the St. Louis physicians had discontinued the two medications, defendant continued to obtain refills of the two medications through Dr. Sullivant and Children’s Mercy Hospital in Kansas City. Dr. Sullivant and the other Kansas City doctors did not know that P.K. was receiving medical treatment in St. Louis.

P.K. was discharged from the hospital in St. Louis in the middle of May 2014. At the time, P.K. still had a nasogastric (NG) tube in place, for feeding and medications.³

Defendant rejected the option of placing P.K. in a short-term inpatient facility. She instead wanted to return home with the NG tube in place. Defendant wanted to be the one to feed P.K. and give him his medications. Defendant demonstrated no difficulties in using the NG tube, and so physicians sent P.K. home.

Thirteen days later, defendant and P.K. returned to St. Louis Children’s Hospital because P.K.’s symptoms were "building up." P.K. was having trouble sleeping and was more unsteady. Physicians readmitted P.K. to the hospital. During the ensuing month-long admission, P.K, suffered a very severe episode where his level of consciousness became so impaired that he lost his gag reflex and he was no longer protecting his airway. Physicians had to insert a breathing tube and place P.K. on a ventilator so that P.K. could breath. He was at risk of dying.

P.K.’s admission to St. Louis Children’s Hospital in March of 2014 began a ten-month period of repeated hospitalizations for P.K. In all, between March 2014 and January 2015, P.K. was admitted to St. Louis Children’s Hospital nine times and hospitalized a total of 168 days. He ultimately underwent surgery for placement of a gastrostomy tube (G-tube ) in his stomach, which allowed for the administration of food, liquid, and medications...