State of Iowa v. Fontae C. Buelow ( 2020 )


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  •                IN THE SUPREME COURT OF IOWA
    No. 18–0733
    Submitted September 16, 2020—Filed December 11, 2020
    STATE OF IOWA,
    Appellee,
    vs.
    FONTAE COLE BUELOW,
    Appellant.
    On review from the Iowa Court of Appeals.
    Appeal from the Iowa District Court for Dubuque County, Monica L.
    Zrinyi Wittig, Judge.
    The State seeks further review of a court of appeals decision to grant
    a new trial due to exclusion of medical records and limitation of an expert’s
    review of the records. DECISION OF COURT OF APPEALS AFFIRMED;
    DISTRICT COURT JUDGMENT REVERSED AND REMANDED.
    Christensen, C.J., delivered the opinion of the court, in which Appel,
    Waterman, McDonald, Oxley, and McDermott, JJ., joined. Mansfield, J.,
    took no part in the consideration or decision of the case.
    David N. Fautsch (argued) and Elisabeth A. Archer of Weinhardt Law
    Firm, Des Moines, for appellant.
    2
    Thomas J. Miller, Attorney General, Genevieve Reinkoester (argued),
    Assistant Attorney General, C.J. May, County Attorney, and Brigit A.
    Barnes, Assistant County Attorney, for appellee.
    3
    CHRISTENSEN, Chief Justice.
    In this case, defendant, Fontae Buelow, is accused of murdering
    Samantha Link. Buelow claims Link committed suicide. A jury convicted
    Buelow of second-degree murder. We must decide whether Link’s mental
    health records are admissible as evidence of Link’s suicidal disposition.
    The mental health records contain discussion of Link’s prior suicide
    attempts, statements of suicidal feelings, and possible mental health
    diagnoses that may increase the risk for suicide. On appeal, defendant
    argued that (1) the district court erred when it excluded Link’s mental
    health records at trial, (2) the district court erred when it limited the
    defense expert’s review of the medical records to only records from one
    year immediately preceding Link’s death, and (3) the district court erred
    in forbidding lay testimony on Link’s suicidal behavior.       The court of
    appeals reversed on the district court’s evidentiary rulings regarding Link’s
    medical records and remanded for a new trial.
    The State seeks further review of the court of appeals decision that
    held that evidence of Link’s mental health history tending to show a
    suicidal disposition should not be considered character evidence.        The
    State also seeks further review of the court of appeals determination that
    temporal proximity does not keep out the evidence contained within Link’s
    medical records.    Additionally, the State seeks review of the court of
    appeals holding that Buelow should be granted a new trial because the
    exclusion of Link’s medical records and limitation of the expert’s review of
    the records was not harmless error.
    Upon our review, we conclude that evidence of a person’s suicidal
    disposition is not properly analyzed as character evidence under the Iowa
    Rules of Evidence in cases where the defendant alleges suicide. We also
    determine that under the facts of this case, the temporal proximity of the
    4
    medical records is not too remote to be relevant to Buelow’s defense that
    Link committed suicide. Furthermore, we conclude that the exclusion of
    evidence regarding Link’s mental health records and the limitation of
    testimony on those records was not harmless error in this case.
    I. Background Facts and Proceedings.
    Samantha Link, a twenty-one year old, lived with her twenty-five-
    year-old significant other, Fontae Buelow, in a friend’s basement.     On
    March 30, 2017, the couple began the evening at a hotel hot tub. They
    later went to a bar to drink with friends. The couple argued at the bar,
    but they ended up leaving together to go home. They continued to argue
    once home. No one else was present at the residence. Buelow says that
    Link grabbed a knife from a butcher’s block sitting on the kitchen counter
    and stabbed herself. Buelow called 911 and told the operator that Link
    had stabbed herself in the stomach. Buelow also told law enforcement
    that Link had stabbed herself one time in the stomach.        Emergency
    responders pronounced Link dead at the scene. Link was determined to
    have three knife wounds. One of the stab wounds penetrated Link’s heart
    and another went through her lung.         Both of these wounds were
    independently fatal. The third stab wound was also in her chest area. The
    State charged Buelow with first-degree murder. Buelow’s only defense is
    that Link committed suicide by stabbing herself.
    Buelow filed a motion with the district court seeking Link’s mental
    health, therapy, and counseling records, because he believed the records
    might contain exculpatory evidence that would bolster his suicide defense.
    The district court reviewed the medical records in camera and then gave
    both parties access to them. The records contained discussion of Link’s
    prior suicide attempts, diagnoses that may increase the risk for suicide,
    5
    and statements of suicidal ideations.              Additionally, Link discussed her
    relationship with a former boyfriend in the records.
    The district court allowed the defense’s expert to review Link’s
    medical records but limited the review to include only records within one
    year’s time before the date of her death. The district court did not allow
    the defense’s expert to comment on the manner of death or whether Link
    acted in conformance with her past conduct.                     Additionally, the court
    excluded all medical records from trial and did not allow lay testimony on
    Link’s suicidal disposition.
    The defense filed a motion requesting the district court to expand its
    prior ruling on the State’s motion in limine. In part, the defense requested
    that the district court allow its expert to review five years of Link’s medical
    records prior to the date of her death, rather than one year, and to admit
    the records at trial. The defense also sought to introduce lay testimony
    from Link’s former boyfriend that during their relationship Link had
    grabbed a knife during an argument. The former boyfriend did not give a
    time frame for this occurrence. The district court ruled that this testimony
    was too remote to be relevant and that it was an attempt to present
    improper character evidence.
    The jury found Buelow guilty of second-degree murder. The court
    of appeals reversed on the district court’s evidentiary rulings and
    remanded for a new trial without addressing Buelow’s remaining issues
    on appeal.1      The State applied for further review, and we granted its
    application.
    1Buelow   additionally raised the issues of (1) whether the district court erred in
    replacing a juror with an alternate after deliberations had started, and (2) whether the
    district court made Buelow choose between his right to an impartial jury and his right to
    a speedy trial, thus resulting in a constitutional violation. Because our holdings on
    Buelow’s evidentiary issues are sufficient for a reversal of the district court’s decision, we
    need not address the remaining issues.
    6
    II. Standard of Review.
    “Evidentiary rulings are generally reviewed for abuse of discretion.”
    State v. Einfeldt, 
    914 N.W.2d 773
    , 778 (Iowa 2018) (quoting State v. Tipton,
    
    897 N.W.2d 653
    , 690 (Iowa 2017)). We reverse for an abuse of discretion
    if evidence was excluded based on an erroneous application of the law.
    Giza v. BNSF Ry., 
    843 N.W.2d 713
    , 718 (Iowa 2014). The standard of
    review for hearsay, however, is for errors at law. State v. Paredes, 
    775 N.W.2d 554
    , 560 (Iowa 2009).
    III. Analysis.
    There are five evidentiary issues that were raised on appeal:
    (1) whether    the    statements    in   Link’s   medical   records     constitute
    inadmissible hearsay evidence under Iowa Rule of Evidence 5.801,
    (2) whether Link’s medical records are too remote to be relevant under
    Iowa Rule of Evidence 5.401, (3) whether evidence of a person’s suicidal
    disposition    is    character   evidence    under   Iowa   Rule   of    Evidence
    5.404(a), (4) whether admission of Link’s medical records are unfairly
    prejudicial under Iowa Rule of Evidence 5.403, and (5) whether it was
    harmless error to exclude Link’s medical records and limit the defense
    expert’s review of them.
    A. Hearsay. The first issue is whether Link’s medical records and
    the statements within them are inadmissible hearsay.               Hearsay is a
    statement that the declarant makes elsewhere than at the current trial,
    which is being offered “to prove the truth of the matter asserted in the
    statement.” Iowa R. Evid. 5.801(c). Hearsay is normally inadmissible.
    Id. r. 5.802. There
    are exceptions to the hearsay rule that allow some
    statements to come in, despite the fact that they are being used to prove
    the matter stated.       There are exceptions for “records of a regularly
    conducted activity,” “statements made for medical diagnosis or treatment,”
    7
    and “statement[s] of the declarant’s then existing state of mind . . . or
    emotional, sensory, or physical condition.”
    Id. r. 5.803(3), (4),
    (6).
    Under Iowa Code section 622.10 (2017), mental health records are
    privileged confidential information that may be accessed by a criminal
    defendant only pursuant to a proper showing. Early on in the litigation,
    Buelow met the initial threshold burden laid out in section 622.10 for
    in camera review of Link’s medical records by establishing that the records
    possibly contain exculpatory information, that the information is not
    available from another source, and that there is a compelling need for the
    information so that he may present a defense in the case. A district court
    judge’s ruling that medical records may be disseminated to parties under
    section 622.10 does not guarantee their admissibility, however.
    Link’s medical records are admissible hearsay under the exception
    for records of a regularly conducted activity. Iowa R. Evid. 5.803(6). This
    exception admits “a record of an act, event, condition, opinion, or
    diagnosis” if made at or near the time by someone with knowledge, if the
    record was kept in the course of a regularly conducted activity of the
    organization, and making the record was the regular practice of that
    organization or business. Id.; see also In re Est. of Poulos, 
    229 N.W.2d 721
    , 727 (Iowa 1975) (“We have long held that medical and hospital
    records are admissible, upon proper foundation, as an exception to the
    hearsay rule.”).
    Link’s statements within the medical records regarding her current
    health, feelings, and plans are admissible under the exception allowing for
    “[a] statement of the declarant’s then existing state of mind . . . or
    emotional, sensory, or physical condition.” Iowa R. Evid. 5.803(3). Link’s
    statements within her medical records regarding her history of suicidal
    thoughts are admissible under Iowa Rule of Evidence 5.803(4), which
    8
    allows for statements made for medical diagnosis or treatment. However,
    not all statements made to a health care provider necessarily fit under the
    exception within rule 5.803(4). For example, we have said that there may
    be circumstances in which a patient makes a statement to a physician
    that identifies the patient’s domestic abuser, and that statement will not
    necessarily meet the exception in rule 5.803(4). See State v. Smith, 
    876 N.W.2d 180
    , 188 (Iowa 2016).
    Regarding Link’s medical records, the State concedes that any
    statements made by Link about her prior suicide attempts are not hearsay.
    To the extent that the statements within the medical records either are
    statements of Link’s then existing state of mind or condition or are
    statements made for diagnosis or treatment, the district court erred in
    concluding otherwise.
    B. Relevance.     The second evidentiary issue is whether Link’s
    mental health records and testimony regarding her mental health are
    relevant.   Only relevant evidence is admissible.    Iowa R. Evid. 5.402.
    Evidence meets the test for relevance if “[i]t has any tendency to make a
    fact more or less probable than it would be without the evidence” and “[t]he
    fact is of consequence in determining the action.”
    Id. r. 5.401. Evidence
    is relevant if it can “throw any light upon the matter contested.” State v.
    Knox, 
    236 Iowa 499
    , 514, 
    18 N.W.2d 716
    , 723 (1945). Here, Buelow is
    trying to introduce the medical records and testimony to support his sole
    defense that Link committed suicide. Because the State must prove that
    Buelow killed Link, evidence that negates such a theory is a fact of
    consequence in determining the action. Therefore, the issue is whether
    Link’s medical records and related admissible testimony can shed any light
    on whether or not she committed suicide.
    9
    The State contends that much of the information in the medical
    records, particularly past suicide attempts, is too remote to be admissible.
    An objection based on remoteness essentially raises an issue
    of relevancy. “While remoteness in point of time does not
    necessarily render evidence irrelevant, it may do so where the
    elapsed time is so great as to negative all rational or logical
    connection between the fact sought to be proved and the
    remote evidence offered in proof thereof.”
    State v. Engeman, 
    217 N.W.2d 638
    , 639 (Iowa 1974) (quoting 1 Clifford S.
    Fishman & Anne T. McKenna, Jones on Evidence, § 4:1, at 380 (6th ed.
    1972)). This court has said that “for remoteness, no precise timetable may
    be set.” Godbersen v. Miller, 
    439 N.W.2d 206
    , 210 (Iowa 1989).
    The State believes that evidence of prior suicide attempts and
    suicidal tendencies should only be admissible if the attempts or ideations
    happened near in time to the death of the deceased. See State v. Seacat,
    
    366 P.3d 208
    , 221 (Kan. 2016) (affirming district court’s holding that prior
    suicide attempts and contemplations three years prior to alleged suicide
    were not relevant to the deceased’s state of mind at death); Commonwealth
    v. Trefethen, 
    31 N.E. 961
    , 962–63 (Mass. 1892) (admitting decedent’s
    suicidal statement made one day before her death but suggesting that the
    statement may have been irrelevant if made two years prior and under
    different circumstances).
    Buelow wants to expand his expert’s review of Link’s medical and
    mental health records to a period of five years before Link’s death and
    admit records that show Link’s suicidal disposition. He also wants to
    admit testimony from a former boyfriend on Link’s suicidal behavior. The
    discussion of Link’s prior suicide attempts occurred a little under three
    years from the date of her death. Although the former boyfriend did not
    recall the date of the argument the defense sought for him to testify to,
    their relationship had ended just eight months prior to Link’s death. The
    10
    issue is whether the testimony and Link’s medical records showing a prior
    suicide attempt and suicidal disposition are too remote to have any
    tendency to make it more or less probable that Link later committed
    suicide.
    Over one hundred years ago, this court was faced with a similar fact
    pattern in State v. Meyer, in which the defendant was charged with
    murdering his wife and asserted suicide as his defense. 
    180 Iowa 210
    ,
    214, 
    163 N.W. 244
    , 245 (1917). There, we said that evidence tending to
    show a predisposition to suicide is admissible.
    Id. at 214, 163
    N.W. at
    246; see also 41 C.J.S. Homicide § 332, at 64–65 (2014) (“Where the theory
    of the defense is that the deceased committed suicide, any evidence
    otherwise competent tending to show that the deceased came to his or her
    death by the deceased’s own act is admissible.”). “Such predisposition
    may be shown by acts or declarations of the deceased within such
    reasonable time before the killing as that there may have been some
    tendency to establish such a condition of mind when this happened.”
    Meyer, 180 Iowa at 
    214, 163 N.W. at 246
    .
    In State v. Beeson, another homicide case from the early 1900’s, this
    court similarly determined that the trial court had erred in keeping
    evidence of the deceased’s suicidal disposition out. 
    155 Iowa 355
    , 
    136 N.W. 317
    , 321 (1912). This court cited several other courts that held that
    suicidal declarations made as far back as three to six years prior to the
    alleged murder were admissible to support a theory of suicide.
    Id. at 355, 136
    N.W. at 321 (citing People v. Conklin, 
    67 N.E. 624
    (N.Y. 1903);
    Blackburn v. State, 
    23 Ohio St. 146
    (1872)).
    Evidence of an alleged victim’s suicidal disposition has been
    admitted in more recent years in State v. Marti. 
    290 N.W.2d 570
    , 575 (Iowa
    1980).     There, the defendant was initially charged with murdering his
    11
    girlfriend.
    Id. At trial, evidence
    was allowed in showing that the deceased
    was depressed, had made suicidal statements, and had spoken to others
    about joining her two brothers who had committed suicide.
    Id. In analyzing relevance
    in the present case, a New Mexico Supreme
    Court case held that suicide attempts going back more than ten years were
    relevant to an alleged homicide when the defense was suicide. See State
    v. Stanley, 
    37 P.3d 85
    , 90 (N.M. 2001); see also State v. Jaeger, 
    973 P.2d 404
    , 407 (Utah 1999) (determining that mental health records from three
    to four years prior to an alleged homicide were relevant when the defense
    was suicide).
    While we understand that much can change in even one-year’s time,
    especially considering Link was participating in mental health treatment,
    the State did not present any medical opinions or psychiatrist’s opinions
    as to why there can be no “rational or logical connection” between a suicide
    attempt and an alleged suicide three years later. State v. 
    Engeman, 217 N.W.2d at 639
    (quoting Fishman § 4:1, at 380). Relevance decays as time
    elapses, but for a young woman of twenty-one, suicide attempts and
    mental health diagnoses from a few years prior are clearly relevant to the
    question of whether she took her own life or was killed by Buelow.
    Therefore, we determine that Link’s mental health records and testimony
    relating to her suicidal disposition are relevant in this case.
    C. Character Evidence.       The third evidentiary issue is whether
    evidence of a person’s suicidal disposition is properly characterized as
    character evidence.    The district court concluded that under State v.
    Jacoby, it was required to exclude Link’s mental health records because
    Buelow did not bring the deceased’s character into issue by raising a self-
    defense claim. See 
    260 N.W.2d 828
    , 837 (Iowa 1977). On appeal, the
    State did not cite Jacoby in its brief but instead offered a new rule in which
    12
    temporal proximity is the determining factor in whether mental health
    evidence is character evidence. For the reasons stated above, we do not
    find this argument persuasive.
    Iowa Rule of Evidence 5.404(a)(1) keeps out “evidence of a person’s
    character or character trait” if it is being used “to prove that on a particular
    occasion the person acted in accordance with the character or trait.”
    Subsection (b) of the rule also prohibits “[e]vidence of a crime, wrong, or
    other act” when it is used “to show that on a particular occasion the person
    acted in accordance with the character.”
    Id. r. 5.404(b)(1) (emphasis
    added). The question we must answer in this case is whether a suicidal
    disposition is a character trait. If not, then evidence that is being used to
    prove Link’s suicidal disposition in this case should not have been
    excluded as character evidence.
    The Iowa Rules of Evidence do not define “character.” According to
    one commentator, evidence of a suicidal disposition should be analyzed
    under the character evidence rules.        See 7 Laurie Kratky Doré, Iowa
    Practice Series: Evidence § 5.404:3(A) & n.5, at 245 (2019–2020 ed. 1999).
    The Iowa Practice Series for Evidence reads the exception in rule
    5.404(a)(2)(A) to permit “[i]ntroduction of victim character testimony by an
    accused . . . in any criminal case but will generally be available only to
    establish self-defense, some defenses in sexual abuse cases, and a suicide
    defense in a murder prosecution.”
    Id. (footnote omitted) (noting
    that “the
    suicidal characteristics of the victim could be relevant”).       However, no
    explanation is given for why a victim’s suicidal disposition should be
    analyzed under the character evidence rules.
    This court has said, “[r]oughly stated, character is what a man
    actually is, while reputation is what his neighbors say he is.” State v.
    Poston, 
    199 Iowa 1073
    , 1074, 
    203 N.W. 257
    , 258 (1925). “[Q]uarrelsome,
    13
    violent, aggressive or turbulent character” is character evidence. Klaes v.
    Scholl, 
    375 N.W.2d 671
    , 675 (Iowa 1985) (quoting 
    Jacoby, 260 N.W.2d at 838
    ); see also State v. Webster, 
    865 N.W.2d 223
    , 243 (Iowa 2015)
    (determining that a party’s act of striking his ex-wife was relevant to
    proving a violent character). On the other end of the spectrum, evidence
    used to prove a person’s traits for “honesty, integrity, and good citizenship”
    or “peacefulness and nonviolence” is considered character evidence. State
    v. Hobbs, 
    172 N.W.2d 268
    , 271 (Iowa 1969).
    Thus, Iowa caselaw shows a framework of character evidence being
    “good” or “bad” traits of a person.         See 1 Kenneth S. Broun et al.,
    McCormick on Evidence, § 186 Character, in general, at 1131 (Robert P.
    Mosteller et al. eds., 8th ed. 2020) (describing character traits as
    “blameworthy    or   praiseworthy”);    Character evidence,    Black’s Law
    Dictionary (11th ed. 2019) (defining character evidence as “[e]vidence
    regarding someone’s general personality traits or propensities, of a
    praiseworthy or blameworthy nature; evidence of a person’s moral
    standing in a community”).
    The State concedes that mental health illnesses do not fit within the
    traditional framework of character evidence and suggests that the question
    in this case “should not be whether a person’s mental health history is
    character evidence, but rather, whether the character evidence rules
    should apply to this mental health history.” The State argues that rule
    5.404 should exclude evidence if its only use is to establish propensity to
    act in a certain way. Under the State’s theory, the character evidence rules
    apply to Link’s mental health history, because Buelow is offering the
    evidence to prove Link’s propensity for self-harm. This reads rule 5.404(b)
    too broadly.    As the United States Supreme Court has said on the
    analogous Federal Rule of Evidence 404(b), the rule only comes into play
    14
    to “protect[] against the introduction of extrinsic act evidence when that
    evidence is offered solely to prove character.” Huddleston v. United States,
    
    485 U.S. 681
    , 687, 
    108 S. Ct. 1496
    , 1500 (1988) (emphasis added).
    Evidence of a person’s prior behavior or act may be introduced “if there is
    a noncharacter theory of relevance and the evidence is material to a
    legitimate issue.” State v. Plain, 
    898 N.W.2d 801
    , 814 (Iowa 2017). Link’s
    prior suicidal behavior stems from mental health issues rather than from
    a character trait.   Thus, evidence of Link’s suicidal disposition has a
    noncharacter theory of relevance and should not be barred by rule
    5.404(b).
    The conclusion that evidence of a suicidal disposition is not
    character evidence follows past Iowa precedent, which has allowed in
    evidence of victims’ suicidal dispositions and ideations to support the
    criminal defendant’s defense of suicide in homicide cases. See 
    Marti, 290 N.W.2d at 575
    ; Meyer, 180 Iowa at 
    214, 163 N.W. at 246
    ; 
    Beeson, 155 Iowa at 362
    –63, 136 N.W. at 320.
    In its application for further review, the State cites a homicide case,
    State v. Heemstra, to support its contention that treating mental health
    records as character evidence is not a novel concept. 
    721 N.W.2d 549
    (Iowa 2006), superseded in part by statute, 2011 Iowa Acts ch. 8, § 2
    (codified at Iowa Code section 622.10(4)(a)(2) (2013)), as recognized in State
    v. Leedom, 
    938 N.W.2d 177
    , 190 (Iowa 2020). In Heemstra, the defendant
    had asserted a self-defense claim and wanted access to the victim’s
    psychotherapist records because he thought the records might contain
    evidence of the victim’s character traits of violence, anger and aggression.
    Id. at 561.
       This court determined that a limited disclosure of the
    information within the decedent’s medical records was appropriate,
    because the information might help bolster the defendant’s self-defense
    15
    claim.
    Id. at 563.
    Heemstra and the present case are distinguishable on
    their facts. In Heemstra, the medical records contained statements that
    showed the victim’s violent tendencies that would fall under character
    evidence when the defendant was claiming self-defense. In contrast, Link’s
    medical records show suicidal ideations and prior suicide attempts. As
    explained above, evidence of a person’s suicidal disposition is not
    character evidence.
    D. Probative Value v. Prejudicial Effect. The fourth evidentiary
    issue is whether Link’s medical records should be excluded from trial
    under Iowa Rule of Evidence 5.403.         Even relevant evidence can be
    inadmissible if the evidence’s probative value is “substantially outweighed
    by a danger of one or more of the following: unfair prejudice, confusing the
    issues, misleading the jury, undue delay, wasting time, or needlessly
    presenting cumulative evidence.” Iowa R. Evid. 5.403 (emphasis added).
    We determine whether evidence should be excluded under rule 5.403
    through a two-part test. 
    Einfeldt, 914 N.W.2d at 784
    . “First, we consider
    the probative value of the evidence. Second, we balance the probative
    value against the danger of its prejudicial or wrongful effect upon the triers
    of fact.” 
    Webster, 865 N.W.2d at 242
    (quoting State v. Huston, 
    825 N.W.2d 531
    , 537 (Iowa 2013)).
    Courts should use rule 5.403 sparingly since it allows for relevant
    evidence to be excluded. Midwest Home Distrib., Inc. v. Domco Indus., Ltd.,
    
    585 N.W.2d 735
    , 745 (Iowa 1998); Williams v. Hedican, 
    561 N.W.2d 817
    ,
    832 (Iowa 1997). “[A]ll powerful evidence is prejudicial to one side. The
    key is whether the danger of unfair prejudice substantially outweighs the
    evidence’s probative value . . . .” State v. Neiderbach, 
    837 N.W.2d 180
    , 202
    (Iowa 2013) (emphasis omitted); see also 
    Huston, 825 N.W.2d at 537
    (noting that it is common in child abuse cases that “much evidence will be
    16
    ‘at least somewhat prejudicial’ ”) (quoting State v. Mitchell, 
    633 N.W.2d 295
    , 301 (Iowa 2001) (Neuman, J., dissenting))). If the balance between
    the evidence’s probative value and prejudicial effect is relatively close, the
    evidence should be admitted.
    The State argues that the evidence was prejudicial because
    symptoms of mental illnesses vary widely and the defense expert’s
    speculation about the symptoms Link experienced on the night of her
    death would create a minitrial on Link’s mental health. This argument
    fails to illustrate why the evidence is unfairly prejudicial to the extent that
    it substantially outweighs its probative value.
    We have explained that the accused’s right to present evidence that
    the deceased committed suicide is “a most important one.” 
    Beeson, 155 Iowa at 362
    , 136 N.W. at 320. Additionally,
    the death of the patient is a fact to consider in balancing the
    rights of a criminal defendant to exculpatory information in
    confidential records. After all, “[t]he holder of the privilege has
    little private interest in preventing disclosure, because he is
    [deceased].”
    State v. Thompson, 
    836 N.W.2d 470
    , 490 (Iowa 2013) (first alteration in
    original) (quoting United States v. Hansen, 
    955 F. Supp. 1225
    , 1226
    (D. Mont. 1997), rev’d on other grounds, No. 97-30214, 
    1998 WL 255192
    (9th Cir. 1998) (unpublished table decision)); see also 
    Heemstra, 721 N.W.2d at 563
    (concluding that disclosure of medical records was
    appropriate where defendant was faced with “the most severe penalty
    provided by our law” and “[t]he subject of the privilege is deceased”).
    Because Buelow’s only defense to his murder charge is that Link
    committed suicide, the probative value of evidence showing Link’s possible
    increased risk for suicide is high. We do not believe that evidence of Link’s
    suicidal disposition will have an unfairly prejudicial effect by creating a
    17
    minitrial on Link’s mental health. See State v. Drach, 
    1 P.3d 864
    , 869
    (Kan. 2000) (noting that a majority of the cited jurisdictions allow into
    evidence a suicide theory “and that the jury is capable of determining its
    validity and attaching the proper weight”). It is not the type of evidence
    that has an “undue tendency to suggest decisions on an improper basis.”
    
    Huston, 825 N.W.2d at 537
    (quoting McClure v. Walgreen Co., 
    613 N.W.2d 225
    , 235 (Iowa 2000) (en banc)). Furthermore, we are not persuaded by
    the State’s argument that Buelow’s expert testimony should be excluded
    because it is mere speculation. The State will have the opportunity to
    cross-examine the defense’s expert witness and present expert testimony
    on its own to try to convince the jury of that. See 
    Williams, 561 N.W.2d at 832
    (explaining that extensive cross-examination better aids the jury in
    performing its function than exclusion of relevant evidence).             The
    admission of evidence regarding Link’s mental health will not be a free-for-
    all. A district court judge has the authority to make discretionary calls for
    the purpose of protecting the integrity of the alleged victim in these cases.
    Therefore, the district court erred in holding that Link’s increased risk for
    suicide was barred by rule 5.403.
    E. Harmless Error.      The final evidentiary issue is whether the
    district court’s exclusion of Link’s medical records and related admissible
    testimony as evidence at trial was harmless error under Iowa Rule of
    Evidence 5.103(a). A reversal is required for the improper admission or
    exclusion of evidence only if the exclusion affected a substantial right of a
    party. Iowa R. Evid. 5.103(a). In a case of nonconstitutional error, “we
    presume prejudice—that is, a substantial right of the defendant is
    affected—and    reverse   unless    the   record   affirmatively   establishes
    otherwise.” State v. Sullivan, 
    679 N.W.2d 19
    , 30 (Iowa 2004). This court
    has “relied on the existence of overwhelming evidence in finding harmless
    18
    error.” State v. Parker, 
    747 N.W.2d 196
    , 210 (Iowa 2008) (overwhelming
    guilt was present when multiple eyewitnesses identified the defendant, the
    defendant admitted to another that he committed the crime, and the
    defendant’s alibi could not be corroborated).
    A criminal defendant’s right to present evidence that the deceased
    committed suicide is “a most important one.” 
    Beeson, 155 Iowa at 362
    ,
    136 N.W. at 320. Buelow’s only defense in this case is that Link stabbed
    herself. Because the district court did not allow admission of any of Link’s
    medical records or related admissible testimony, Buelow was barred from
    introducing evidence that Link had prior suicide attempts, suicidal
    ideations, and possible medical diagnoses that would increase her risk for
    suicide. See 
    Paredes, 775 N.W.2d at 571
    (declining to find harmless error
    when evidence was excluded at trial that “would have clearly aided the
    defense in its only available theory”).
    Furthermore, we do not conclude that the State’s case against the
    defendant rises to the same amount of overwhelming evidence of guilt we
    have found sufficient to avoid harmless error in the past. Unlike State v.
    Parker, there were no eyewitnesses. Both sides presented expert evidence
    that suggested the physical scene of the death better fit with their theory
    of what occurred.      Therefore, exclusion of the medical records and
    limitation of related admissible testimony was not harmless error in this
    case.
    IV. Conclusion.
    For the aforementioned reasons, the district court judgment is
    reversed and remanded, and we need not address the remaining issues on
    appeal.
    DECISION OF COURT OF APPEALS AFFIRMED; DISTRICT
    COURT JUDGMENT REVERSED AND REMANDED.
    All justices concur except Mansfield, J., who takes no part.