Court of Appeals of Missouri, Eastern District, Third Division
from the Circuit Court of St. Louis County Honorable Joseph
LAWRENCE E. MOONEY, JUDGE
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.
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.
and Procedural Background
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,  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.
Besins in Kansas City
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.
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.
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 41'1 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
Louis Hospitalization and Beginning of Treatment in St.
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. 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.
Louis physicians ruled out an exacerbation of P.K.'s
underlying illnesses. Tests also showed that P.K.'s shunt
was functioning properly, 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-spectrum seizure medication called
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.
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. 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
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.
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 directly into the stomach, rather
than through the NG tube. The G-tube was necessary, as had
been the NG tube, because P.K, was often comatose and unable
to eat, drink, or swallow medication. Staff taught defendant
how to use the G-tube tube, as they had done with the NG
August of 2014, the St. Louis doctors started P.K. on weekly
pheresis plasma-exchange treatments. Pheresis is similar to
dialysis, in that blood is taken out of the patient,
filtered, and then returned to the patient's body. The
pheresis process removes auto-antibodies and medications from
a patient's blood. P.K. reported for his weekly
treatments with varying degrees of unresponsiveness. He would
arrive very sleepy, very unsteady, and sometimes unable to
walk on his own. He could not control his body and was unable
to point at an object. He was confused at times and had
would be a little more alert immediately after treatment.
Defendant reported that P.K. would get better for a few days
after the pheresis treatment, become more active, alert, and
able to walk with steadier movement, but then his symptoms
would return, "like clockwork," necessitating yet
another treatment the following week. P.K. underwent at least
twenty pheresis treatments in the time period between August
2014 and the end of January 2015.
Refills from Dr. Sullivan; Missed & Cancelled
noted, while P.K. was under the care of the doctors at St.
Louis Children's Hospital, and after those physicians had
discontinued and replaced the Risperdal and Trileptal,
defendant continued to request refills for those medications
from the Kansas City doctors. Defendant even requested
refills on at least two occasions while P.K. was hospitalized
in St. Louis. Dr. Sullivant approved the requests because
P.K. was scheduled for an appointment with her on September
12th. However, defendant and P.K. did not show for
that appointment. When asked why, defendant told Dr.
Sullivant's staff that P.K. had seen doctors in St.
Louis, and that there had been no change in P.K.'s
psychiatric medications, as the St. Louis doctors "did
not want to complicate the picture." Defendant further
stated that they did not show for the September
12th visit because she had rescheduled the
appointment to September 19th. Dr. Sullivant was
wary of this excuse because she did not have clinic on
September 19th, and her staff never scheduled an
appointment during a time when she did not have clinic.
Defendant rescheduled the appointment for September
22th, but then rescheduled that appointment,
stating that she and P.K. had missed a flight and were stuck
out of town. Defendant rescheduled the appointment for
October 13th, but then, without giving a reason,
rescheduled the appointment for December 8th.
During this time, defendant twice requested refills for
Risperdal. Dr. Sullivant approved the requests, but in
November told defendant that she would not authorize any more
refills if defendant and P.K. did not come in for the
to Dr. Sullivant, December 2014
and P.K. arrived at Dr. Sullivant's office on December
8th, just five days after P.K.'s pheresis
treatment in St. Louis. When P.K. arrived for that treatment,
he "did not look great." He had what appeared to be
a cold, and had trouble breathing during his treatment,
necessitating doctors placing P.K. on oxygen, and admitting
him to the hospital for overnight observation. Defendant did
not tell Dr. Sullivant about this, or that P.K. was
undergoing pheresis treatments in St. Louis. Rather, she told
Dr. Sullivant that things were "going much better"
since their last visit in March. Defendant related that P.K.
had been diagnosed with AE while in St. Louis, but then told
Dr. Sullivant that P.K, had gradually improved, and that the
encephalitis had essentially resolved. However, P.K. had not
improved, and at the time of this office visit with Dr.
Sullivant, he was still being treated for AE by the St. Louis
visit to her office, Dr. Sullivant reviewed the medications
that P.K. was taking, to ensure she had an accurate list. At
this December 8th visit, defendant reported no
changes in P.K.'s medications, except an allergy
medication. Defendant did not tell Dr. Sullivant that St.
Louis doctors had discontinued Risperdal and Trileptal and
replaced them with similar medications. And she did not tell
Dr. Sullivant about the chemotherapy drugs that P.K. was
taking, which we will discuss below. Prior to this visit, Dr.
Sullivant received a letter indicating that someone in St.
Louis had been prescribing Seroquel for P.K. Seroquel was the
replacement drug for Risperdal. When Dr. Sullivant asked
about this, defendant stated that the St. Louis doctors had
briefly prescribed Seroquel for P.K., but that P.K. was no
longer taking it. Defendant did not volunteer this
information but only mentioned it when Dr. Sullivant
specifically inquired about the drug. However, the St. Louis
doctors had not discontinued Seroquel, and pharmacy records
showed that the prescription was being filled regularly.
Sullivant directly communicated with P.K. and the defendant
for the last time at this appointment. At the time defendant
and P.K. left the office, Dr. Sullivant was still prescribing
Risperdal and Trileptal for P.K. She would not do so for
long, however, as Dr. Sullivant and the St. Louis doctors
connected the following month.
Diagnosis Questioned; ...