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State v. Kinsella

Court of Appeals of Missouri, Eastern District, Third Division

March 5, 2019


          Appeal from the Circuit Court of St. Louis County Honorable Joseph S. Dueker


         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

         RK.'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 Besins 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 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 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 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 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 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 rube.

         Pheresis Treatments Besin

         In 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 difficulty talking.

         P.K. 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.

         Continued Refills from Dr. Sullivan; Missed & Cancelled Appointments

         As 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 December appointment.[4]

         Return to Dr. Sullivant, December 2014

         Defendant 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 doctors.

         On each 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.

         Dr. 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.

         AE Diagnosis Questioned; ...

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