State of Iowa v. Todd W. Adams ( 2022 )

IN THE COURT OF APPEALS OF IOWA
No. 21-0916
Filed October 5, 2022
STATE OF IOWA,
Plaintiff-Appellee,
vs.
TODD W. ADAMS,
Defendant-Appellant.
________________________________________________________________
Appeal from the Iowa District Court for Clinton County, Patrick A. McElyea,
Judge.
A defendant appeals his conviction for five counts of second-degree sexual
abuse and two counts of indecent contact with a child. AFFIRMED.
Martha J. Lucey, State Appellate Defender, and Melinda J. Nye, Assistant
Appellate Defender, for appellant.
Thomas J. Miller, Attorney General, and Zachary Miller, Assistant Attorney
General, for appellee.
Heard by Bower, C.J., Tabor, J., and Gamble, S.J.*
*Senior judge assigned by order pursuant to Iowa Code section 602.9206
(2022).
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TABOR, Judge.
A jury found Todd Adams guilty of five counts of sexual abuse in the second
degree and two counts of indecent contact with a child for offenses against three
of his step-granddaughters. On appeal, he contends the district court abused its
discretion in excluding evidence that the girls’ mother had a motive to coach them
to lie. He also challenges the admission of hearsay from a nurse who relayed
statements made by two of the girls while being treated at a child protection center
(CPC). Because Adams failed to preserve his first challenge, we do not reach the
merits. On the hearsay claim, we find the nurse’s testimony was admissible under
the exception for statements made for the purpose of medical diagnosis or
treatment. Thus, we affirm.
I. Facts and Prior Proceedings
Adams and Carol Bower met in 2014. They married on Halloween in 2016,
making Adams the step-father to Bower’s daughter Billie and the step-grandfather
to Billie’s four young daughters: V.S., A.S, M.H, and E.H.1 Billie’s daughters
enjoyed staying at their grandparents’ house because it had toys, games, and farm
animals; they would often spend nights and weekends there. But Billie had a
fraught relationship with her mother. The pretrial record shows that Billie had a
history of substance abuse and her mother took steps to have her involuntary
committed.
Adding to the family’s issues, both Bower and Billie knew Adams was a
registered sex offender. He was convicted of second-degree sexual abuse in
1 V.S. was born in 2009, A.S. in 2011, M.H. in 2013, and E.H. in 2014.
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1994. His victim was five years old. Given Adams’s history, from time to time,
Billie asked the girls if anyone had touched them inappropriately.
The girls stopped going to their grandparents’ house in August 2019 after
E.H. told Billie that “Papa Todd” had repeatedly touched her “private parts.” After
first denying any abuse, sisters V.S. and M.H. eventually told their mother that
Adams had touched them too. The girls alleged Adams began inappropriately
touching them as early as October 2016 when he married their grandmother.2 The
fourth girl, A.S., said she was not touched and did not see anything happen to her
sisters. Billie contacted the Iowa Department of Human Services (DHS),3 which
scheduled an appointment for the girls at the St. Luke’s Hospital CPC. According
to Billie, she also told Bower about the girls’ allegations, and Bower reacted by
pursuing an involuntary commitment of Billie two days later.
In early October 2019, all four girls were interviewed at the CPC. A.S., E.H.,
and M.H. said Adams did not touch them. But V.S. said he did touch her. A DHS
worker attended the girls’ interviews and contacted law enforcement.
Law enforcement scheduled another CPC visit for the older sisters, V.S.
and A.S., in late October. Their stories remained the same. Law enforcement
then scheduled the younger sisters, M.H. and E.H., for another CPC visit in mid-
November. During this second appearance, the younger sisters were examined
by sexual assault nurse examiner Kristen Kasner.4 During their medical exams,
2 All the girls were under twelve years old during this time frame.
3 That department recently merged with the Iowa Department of Public Health. But
because it encompassed only human services throughout this investigation, we
will continue to use the acronym DHS in this opinion.
4 Their father accompanied them to the appointment. But the record is unclear
when he was in the exam room.
4
the girls told Kasner that Adams had touched them and described the contact
between their body parts. The same day as those exams, Kasner shared the girls’
revelations with the DHS and law enforcement.
In August 2020, the State charged Adams in a ten-count trial information:
five counts of sexual abuse in the second degree (three against M.H. and two
against E.H.); two counts of indecent contact with V.S.; and three counts of
dissemination of obscene material to a minor.5 Pretrial, the State moved to exclude
any evidence of Billie’s chronic drug use as irrelevant. The State also moved to
exclude evidence of her past involuntary commitment, orchestrated by Bower, as
confusing and potentially prejudicial. As a “preliminary matter” the court excluded
that evidence, “not wanting to turn this into a trial about Billie.” Also pretrial, Adams
moved to exclude any hearsay statements the girls made to nurse Kasner during
their exams; the State resisted. The district court reserved ruling on that hearsay
objection until trial.
Once it came to trial, the younger girls were asked why they denied that
Adams had touched them in their first CPC interviews. M.H. explained that she
“was nervous to say and kind of scared.” E.H. testified she only remembered one
interview and if she did say Adams did not touch it was because she forgot.
Before nurse Kasner’s testimony, the State made an offer of proof
concerning the younger girls’ statements during their medical examinations. The
district court ruled the statements were admissible under the hearsay exception
5The original trial information also charged two counts of lascivious conduct with
a minor. But the State dismissed those counts before trial. The district court
granted judgment of acquittal on the obscenity charges.
5
for statements for the purpose of medical diagnosis or treatment. During her
testimony, Kasner recalled that M.H. “referred to her mom maybe doing drugs.”
Based on that statement, Adams renewed his objection to the court’s exclusion of
Billie’s history of substance abuse. The court reaffirmed its ruling excluding that
evidence.
At the close of trial, the jury found Adams guilty of five counts of sexual
abuse in the second degree and two counts of indecent contact with a child.
Because Adams was a recidivist, the district court sentenced him to life in prison
on the five sexual-abuse offenses and to four-year indeterminate sentences for
each of the indecent-contact offenses. Adams now appeals.
II. Analysis
A. Drug-Use and Involuntary Commitment of the Girls’ Mother
Adams first contends that the district court abused its discretion in granting
the State’s motion in limine excluding evidence of Billie’s chronic drug use and her
involuntary commitment facilitated by Bower. He claims this evidence was relevant
to his defense that the girls fabricated their allegations and Billie’s motive to
encourage that fabrication. He contends the evidence would not have unduly
complicated issues for the jury.
Preempting our consideration of this claim, the State argues Adams failed
to preserve error by failing to renew his objection at trial and by failing to present
an offer of proof to show Billie’s past drug use and involuntary commitment. In
response, Adams argues that the written limine ruling did not show further action
was needed to preserve his objection to either the evidence of Billie’s drug-use or
the related issue of her involuntary commitment. He believes the pretrial ruling
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reached the ultimate issue and was the final word. As for the offer of proof, he
contends that the dispute over the timing of the involuntary commitment would only
require asking Billie and Bower “a few questions” at trial.
But the court’s pretrial ruling tells a different story:
I think as a general matter I’m going to overrule your objection
[to excluding evidence of chronic drug history]. I tend to agree with
counsel that if there’s a specific day that you’re asking about and you
have information that indicates there may have been drug use on
that day that would impact, then I think we’ll address that at the trial
prior to asking any questions. But the fact that someone generally
uses drugs to then use them—use that information to impeach them
I think is a bridge a bit too far.
....
I’m inclined to overrule the objection [to excluding evidence of
the involuntary commitment] largely from the standpoint that I do
think that this is at the very least under [Iowa Rule of Evidence 5.]403
looking at confusion of the issues and it may be potentially relevant
testimony but I think it’s going to turn the jury’s focus to something
else rather than whether or not the alleged actions between [Adams]
and the victims happened. So I don’t want to turn this into a trial
about Billie by allowing any of this testimony.
So at this point from a preliminary matter the Court’s going to
overrule the objection . . . .
The district court ruled that evidence of Billie’s chronic drug use was prohibited,
meaning Adams did not need to raise the issue again at trial. See Quad City Bank
& Tr. v. Jim Kircher & Assocs., P.C., 804 N.W.2d 83, 90 (Iowa 2011) (stating that
objections based on a limine ruling must be renewed unless the ruling “leaves no
question that the challenged evidence will or will not be admitted at trial”). But the
ruling on her involuntary commitment was explicitly “preliminary”—requiring an
objection and offer of proof at trial. See State v. Webster, 865 N.W.2d 223, 242
(Iowa 2015) (finding claim not preserved where pretrial request to admit evidence
was “preliminarily denied”).
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Sensing a sinking ship, Adams now tethers his involuntary-commitment
claim to the substance-abuse history. He argues that by renewing his request to
offer evidence of Billie’s drug use when nurse Kasner “opened the door” during her
testimony, he also revived the involuntary-commitment claim because those
issues were so “tightly intertwined.” But that trial objection did not cover both
issues. Defense counsel argued only that Billie’s drug use “created an unstable
household,” offering an alternate explanation for the stress on the children that had
been attributed to Adams’s alleged sexual abuse. The court made no further
mention of the commitment, beyond reminding witnesses to not discuss it. Thus,
Adams failed to preserve error on the exclusion of Billie’s involuntary commitment.
Finally, assuming Adams did preserve his relevancy claim as to Billie’s drug
history, that is not the focus of his argument now. On appeal, he has abandoned
any claim that her drug use, standing alone, was relevant. See MidWestOne Bank
v. Heartland Co-op, 941 N.W.2d 876, 885 n.3 (Iowa 2020) (declining to reach issue
abandoned by party on appeal). His appellate position is that “Billie’s extensive
drug use and resulting involuntary commitment” were relevant to his defense that
the girls “fabricated their allegations at Billie’s behest to punish her mother for
having her committed.” Because that evidentiary issue is not properly before us,
we decline to reach the merits.
B. Nurse’s Hearsay Statements from E.H. and M.H.
Adams next claims the district court erred in allowing nurse Kasner to testify
over his hearsay objection. He argues the hearsay exception for statements made
for medical diagnosis or treatment in Iowa Rule of Evidence 5.803(4) did not apply
to Kasner’s testimony. The State defends the district court ruling.
8
As opposed to most evidentiary issues, we review hearsay rulings for errors
at law. State v. Paredes, 775 N.W.2d 554, 560 (Iowa 2009). That’s because “a
district court ‘has no discretion to admit hearsay.’” State v. Veverka, 938 N.W.2d
197, 202 (Iowa 2020) (quoting State v. Dullard, 668 N.W.2d 585, 589 (Iowa 2003)).
We presume improper admission of hearsay evidence is prejudicial unless the
record shows otherwise. State v. Plain, 898 N.W.2d 801, 810 (Iowa 2017). But
we still defer to the district court’s factual findings when they are supported by
substantial evidence. Id.Before allowing Kasner to share the girls’ out-of-court statements with the
jurors, the court received information about her background and process. Kasner
is a licensed nurse and certified sexual assault nurse examiner for children. She
works at St. Luke’s Hospital and met M.H and E.H. (along with their father) there
in November 2019. As nurses do as part of a medical examination, Kasner
checked the girls’ height, weight, and blood pressure. She also explained to them
the purpose of their appointment. She then asked each girl an open-ended
question about why they were there, and gave them a “head-to-toe” examination.
With that background, the court allowed Kasner to testify about the
information she gathered from M.H and E.H. Kasner told the jury that she asked
the girls about their “family history” and “social history” such as who lived at their
house and where they went to school. Kasner also explored the girls’ behavioral
and medical history and did a “review of the systems”—asking the girls if they were
eating, sleeping, and breathing properly. Both children complained of constipation
and M.H. had a stuffy nose and cough but neither had other injuries. Kasner
outlined her physical findings to the court.
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Most important for this appeal, Kasner recounted that after she asked M.H
and E.H. why there were at the CPC, they revealed that Adams had touched
“private” areas of their bodies. Kasner explained that it was “standard medical
practice to say, what can I do for you today?” When Kasner asked E.H. why she
was there, the child identified Adams as her abuser. The child told the nurse that
Adams “touched her [with his fingers] right here” while motioning to the area
between her legs. When Kasner posed the same routine question to M.H., the girl
said she was there because her “mom [was] maybe doing drugs and people [were]
doing bad things to me.” M.H. clarified that the “bad things” were Adams touching
her inappropriately. M.H. told Kasner that Adams touched her with “his hand and
his tail.” M.H. told the nurse that Adams “put his tail in her bottom” and that it hurt
to “poop” or “pee” afterward.
Adams objected to Kasner’s testimony on hearsay grounds, asserting the
medical exception did not apply. The defense argued that the CPC
“masquerade[s] as a health care entity when in truth they’re acting as an extension
of law enforcement.” The court overruled the objection finding the evidence fell
within the exception for statements made for the purpose of medical diagnosis or
treatment. See Iowa R. Evid. 5.803(4).
Under this exception, a statement is admissible if it is “made for—and is
reasonably pertinent to—medical diagnosis or treatment; and . . . [d]escribes
medical history, past or present symptoms or sensations, or the inception or
general cause of symptoms or sensations.” Iowa R. Evid. 5.803(4)(A)–(B).
Typically, such statements are “likely to be reliable because the patient has a
selfish motive to be truthful” given that “the effectiveness of the medical treatment
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rests on the accuracy of the information imparted to the doctor.” State v. Smith,
876 N.W.2d 180, 185 (Iowa 2016) (citations omitted).6
To apply the exception, the hearsay proponent must show two factors.
First, “the declarant’s motive in making the statement must be consistent with the
purposes of promoting treatment.” State v. Hildreth, 582 N.W.2d 167, 170 (Iowa
1998) (quoting State v. Tracy, 482 N.W.2d 675, 681 (Iowa 1992)). “[S]econd, the
content of the statement[s] must be such as is reasonably relied upon in treatment
or diagnosis.” Id. (citation omitted). There is no categorical rule allowing or barring
all testimony from nurses or doctors concerning statements made by children in a
CPC context. State v. Walker, 935 N.W.2d 874, 879 (Iowa 2019).
Adams contends the State failed to meet either factor. As for motive,
Adams argues the State offered no evidence that “the girls were advised or
understood that they needed to tell the truth to nurse Kasner to ensure they
received appropriate medical care.” As for reliance, Adams contends that Kasner’s
true purpose in extracting the girls’ statements, especially on the identity of the
abuser, was to assist law enforcement.
Going in reverse order, we find the second factor easily satisfied. In her
offer of proof, Kasner assured the court that collecting information about what
happened to the girls was part of the “medical model” that guided her decision
6 That selfish motive to be truthful may require a closer look when it comes to
children—as they may not appreciate how important it is for them to tell the truth
to medical professionals. See Olesen v. Class, 164 F.3d 1096, 1098 (8th Cir.
1999) (holding child’s statements to physician were inadmissible if prosecution
could not show child understood medical significance of being truthful); but see
State v. Vaught, 682 N.W.2d 284, 289 (Neb. 2004) (declining “to presume that
children speaking to physicians are not truthful and are not motivated by promoting
medical treatment”).
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making. It informed “what to look for in the exam, what to do, how to treat the
person. That applies to sex abuse as well as ear aches.” When asked about
identifying the perpetrator of the alleged abuse, Kasner agreed that it helped
determine further treatment and how to keep the child physically safe. On this
record, the district court had substantial evidence to find the girls’ statements were
the kind of information reasonably relied upon by medical professionals in deciding
the patient’s appropriate diagnosis and treatment.
Circling back to the first factor, we examine whether the girls made their
statements with the aim to receive medical treatment or, instead, to further the
criminal investigation. In finding the State satisfied this factor, the district court
emphasized several points. First, the nurse asked an open-ended question.
Second, the children disclosed not only the sexual abuse, but symptoms of other
illnesses. For example, M.H. told Kasner that she had a stuffy nose, E.H. had
constipation issues that the nurse wanted to address.
Yet Adams contends this was not enough to show their motives were
consistent with the purpose of promoting treatment because the State failed to
prove that the girls understood they needed to tell Kasner the truth. He points us
to Tracy, which explained that the first factor is met when the healthcare provider
“emphasized to the alleged victim the importance of truthful responses in providing
treatment and the record further indicates that the child’s motive in making the
statements was consistent with a normal patient/doctor dialogue.” 482 N.W.2d at
681 (emphasis added).
The State acknowledges that “explicitly telling the girls they needed to tell
the truth can be helpful” but cites Walker to illustrate that such instruction from the
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care provider is not mandatory. 935 N.W.2d at 880. Like the doctor in Walker,
nurse Kasner followed a medical model of inquiry, explaining the purpose of the
appointment, asking non-leading questions, and reviewing any symptoms that they
presented. Given the similarities between these two sets of facts, we agree that
Walker provides the best guidance for our analysis.
The State distinguishes the girls’ statements to nurse Kasner from the CPC
forensic interview at issue in State v. Skahill. 966 N.W.2d 1, 10 (Iowa 2021).
Skahill held that a child-declarant’s statements to a forensic interviewer did not fall
within the medical-diagnosis exception. Id. But the Skahill court contrasted the
inadmissible forensic interview with the CPC medical examination done before the
interview, describing the child’s statements to that doctor as “the type of
information the medical diagnosis exception is designed to allow into evidence.”
Id. at 9. The Skahill court also contrasted the inadmissible forensic interview with
the admissible statements in Walker, noting the interviewer “wasn’t a physician, a
psychologist, or therapist; there was a separate physician who attended to [the
child] at that time; and [the interviewer’s] questioning was self-described as
‘forensic.’” Id. at 10.
Based on Walker and Skahill, we find the girls’ motives in sharing their
allegations about Adams with nurse Kasner were consistent with the purposes of
promoting treatment and fall within the hearsay exception. Because both factors
are met, the district court did not err in admitting nurse Kasner’s testimony.
AFFIRMED.