State of Tennessee v. Christopher Gatewood ( 2018 )


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  •                                                                                          03/20/2018
    IN THE COURT OF CRIMINAL APPEALS OF TENNESSEE
    AT KNOXVILLE
    January 24, 2018 Session
    STATE OF TENNESSEE v. CHRISTOPHER GATEWOOD
    Appeal from the Criminal Court for Hamilton County
    No. 292487 Don. W. Poole, Judge
    No. E2017-00653-CCA-R9-CD
    The Defendant, Christopher Gatewood, is charged in the Hamilton County Criminal
    Court with rape of a child. See T.C.A. § 39-13-522 (2014). The State contends in this
    interlocutory appeal pursuant to Tennessee Rule of Appellate Procedure 9 that the trial
    court erred in granting the Defendant’s motion in limine to exclude evidence of the
    alleged victim’s statements to a nurse practitioner on Confrontation Clause grounds. We
    affirm the order of the trial court.
    Tenn. R. App. P. 3 Appeal as of Right; Order of the Criminal Court Affirmed
    ROBERT H. MONTGOMERY, JR., J., delivered the opinion of the court, in which JAMES
    CURWOOD WITT, JR., and D. KELLY THOMAS, JR., JJ., joined.
    Herbert H. Slatery III, Attorney General and Reporter; Nicholas W. Spangler, Assistant
    Attorney General; M. Neal Pinkston, District Attorney General; Boyd Patterson and
    Leslie Longshore, Assistant District Attorneys General, for the appellant, State of
    Tennessee.
    D. Marty Lasley (on appeal) and William Speek (at hearing and on appeal), Chattanooga,
    Tennessee, for the appellee, Christopher Gatewood.
    OPINION
    The Defendant’s charge relates to the alleged rape of his then-twelve-year-old
    stepdaughter, A.J. Defense counsel filed a motion in limine to exclude hearsay evidence
    and statements from non-testifying witnesses. The motion did not address specific
    hearsay or witnesses, but at the hearing on the motion, the parties identified the evidence
    at issue as A.J.’s statements to a nurse practitioner at the Children’s Advocacy Center.
    A.J.’s statements included allegations of vaginal and anal rape the previous evening and
    of past sexual touching by “her dad.” After receiving evidence at the hearing, the trial
    court granted the Defendant’s motion in limine to exclude evidence of A.J.’s statements.
    The court found that the primary purpose of the statements was “testimonial” and, as
    such, admission of them would violate the Defendant’s constitutional right to confront
    adverse witnesses. The State filed a motion for permission to pursue an interlocutory
    appeal pursuant to Tennessee Rule of Appellate Procedure 9, and the trial court granted
    the State’s motion. The State then filed an application for an interlocutory appeal in this
    court, which was granted.
    Facts
    At the hearing on the motion in limine, Ashley O’Barr Haynes, a pediatric nurse
    practitioner at the Children’s Advocacy Center of Hamilton County, testified as an expert
    witness in child sexual assault examination. She said that on August 29, 2013, A.J. and
    A.J.’s mother arrived at the Children’s Advocacy Center and completed paperwork
    related to demographic information and medical history. Nurse Practitioner Haynes said
    that she obtained A.J.’s medical history for the purpose of medical diagnosis and
    treatment and that she did not conduct a forensic interview. She said the interview she
    obtained was “to assure the child is physically safe and that their body and self are safe.”
    She added that it was “important to get a history of what occurred in order to properly
    assess the child.” She said the interview “helps guide the exam so I know what to look
    for.” She agreed that based upon the statements made by a child and the examination of
    the child, she was able to prescribe further treatment, such as medication, counseling, and
    medical treatment.
    Nurse Practitioner Haynes testified that she took the following history from A.J.:1
    A.J. was going to bed when she saw a light come on in her room. A.J. saw “her dad,”
    who moved her and got into bed with her. He removed her pants and underwear and
    raped her vaginally and anally. A.J.’s father did not wear a condom, and A.J. did not
    bleed. The events occurred around 9:00 p.m. on August 28, 2013. On four prior
    occasions in 2012 and 2013, A.J.’s father opened her legs and rubbed her vagina. A.J.
    did not indicate that the prior incidents involved penetration. On the previous evening,
    A.J. first told her mother about the events.
    1
    The State contends in its brief and its oral argument before this court that the information about the alleged offense
    was elicited by an open-ended question posed by Nurse Practitioner Haynes to A.J. The record merely reflects that
    Nurse Practitioner Haynes asked A.J. about what happened and took a statement from A.J. Nurse Practitioner
    Haynes was not asked whether, nor did she state, she obtained the information from A.J. through a single, open-
    ended question. During cross-examination about A.J.’s statements recorded in Nurse Practitioner Haynes’s report,
    Nurse Practitioner Haynes described asking “questions,” including whether the perpetrator had anything on his penis
    and if any bleeding occurred. Nurse Practitioner Haynes also referred to her “discussion with” A.J. regarding the
    approximate time A.J. had gone to bed the previous evening.
    -2-
    Nurse Practitioner Haynes testified that because A.J. reported a sexual assault
    occurring within the past seventy-two hours, “[I]t was decided between myself and law
    enforcement that a rape kit would be necessary to collect.” Nurse Practitioner Haynes
    said she performed a head-to-toe examination and collected the rape kit. She agreed that
    she did not find physical trauma. Nurse Practitioner Haynes said she also performed a
    urinalysis to determine whether A.J. was pregnant and prescribed medication that
    provided prophylaxis for pregnancy and sexually transmitted infections. Nurse
    Practitioner Haynes said A.J. seemed to be reliable and gave a consistent statement but
    acknowledged that A.J. could have been lying, although she had no suspicion that A.J.
    had been untruthful.
    Nurse Practitioner Haynes acknowledged that, at the time she examined A.J., she
    did not have the credentials to conduct a forensic interview pursuant to Tennessee Code
    Annotated section 24-7-123, pertaining to admission of a video recording of a child’s
    interview regarding a sexual assault. She said, however, that she had since obtained the
    certification, although she did not conduct forensic interviews in her employment. When
    asked, “Did you tell [the victim and her mother] you work with law enforcement?”
    Nurse Practitioner Haynes said, “That’s not really part of what I explain to the child.”
    When asked further, “Did you do that, though?” she said, “No.” She responded
    affirmatively when asked, “Did the child know that the purposes of this examination was
    [sic] for her own health benefit?” Nurse Practitioner Haynes did not recall whether a law
    enforcement officer had been present when A.J. arrived at the Children’s Advocacy
    Center, but she said she collected evidence for A.J.’s rape kit and provided it to the
    detective who was working on A.J.’s case. Nurse Practitioner Haynes did not know how
    the victim and her mother were transported to the Children’s Advocacy Center and said
    she assumed they had been instructed to go to the center by the Department of Children’s
    Services (DCS) or law enforcement. When asked, “So it’s your understanding the police
    directed her to you?” Nurse Practitioner Haynes responded, “Police or DCS.”
    The report Nurse Practitioner Haynes prepared relative to her interview and
    examination of A.J. was received as an exhibit. It includes the following information:
    08/29/2013 – Office Visit: Sexual Abuse Medical Examination
    ...
    Sexual Assault Exam
    -3-
    ...
    REASON FOR REFERRAL
    Reason for Referral:        alleged rape
    Date of Occurrence:         8/29/2013
    City of Occurrence:         Chattanooga
    State of Occurrence:        Tennessee
    Date of Exam:               8/29/2013
    ...
    Location of Care:           Children’s Advocacy Center
    Case Worker:                A. Haithcock, DCS Hamilton County
    Referring Agency:           Chattanooga Police Department
    Law Enforcement:            G. Fugh, CPD
    ...
    Patient Instructions:
    1)    The purpose of this exam is to collect evidence and document
    trauma, if present.
    2)     The medical evaluation is not used as the only evidence to support or
    deny that abuse has occurred.
    3)      Most importantly, it is performed to reassure you and your child that
    his [sic] body is okay.
    4)     Medications sent to Wal-Mart include:
    5)     Cefixime 400mg tablet, take one by mouth
    -4-
    6)     Metronidazole 2g tablet, take one by mouth
    7)     Azithromycin 1g tablet, take one by mouth
    8)     Plan B 1.5mg tablet, take one by mouth – if vomiting occurs within
    two hours, will need to call 423-778-9107 to get another dose prescribed.
    Please ask for Ashley O’Barr, Lillie Rucker, or Dr. Karla Garcia.
    9)    Do not take the Plan B until I contact you to inform you urine
    pregnancy tests are negative.
    10)    Recommend counseling.
    11) Recommend return visit at CAC in approximately 4 weeks;
    scheduled for Tuesday, September 24th at 9am.
    12) I will be in touch with Chattanooga Police Department detective
    today. Please call him with any questions or concerns.
    13)    Patient to call if any questions.
    Elsewhere in the report, the “Requesting Physician” is listed as “Chattanooga Police
    Department.”
    The exhibit containing A.J.’s medical records included the paperwork which
    Nurse Practitioner Haynes testified had been completed by A.J. and A.J.’s mother. On
    the line following the question, “Who referred the patient for the exam?” a handwritten
    response states, “Chattanooga Police.” In response to the question, “Is there a law
    enforcement agent (police officer/detective) involved in the case?” the box corresponding
    with “yes” is marked, and a handwritten response states the “name” is “Chatt. P.D.”
    Responses elsewhere indicate A.J.’s primary care physician to be “Whitfield County,”
    that the reason for the examination on August 29, 2013 was “physical for school,” and
    that the “alleged event” occurred on August 28, 2013. The person who completed the
    form expressed concern about “her being permanently damaged physically and scarred
    emotionally.”
    At the hearing, the prosecutor stated that sixteen-year-old A.J. did not live in
    Tennessee and that the State did not intend to call her as a witness at the trial. The
    prosecutor acknowledged, however, that A.J. was not unavailable as a witness. The
    -5-
    prosecutor argued that A.J.’s statements to Nurse Practitioner Haynes were admissible
    hearsay exceptions pursuant to Tennessee Rule of Evidence 803(4) because they were
    statements made for medical diagnosis and treatment. The defense argued that admission
    of the statements would violate his right to confront adverse witnesses. See Crawford v.
    Washington, 
    541 U.S. 36
    (2004). Defense counsel asserted that after A.J. made the
    allegations, she later recanted by telling multiple individuals that she had fabricated the
    allegations. Thus, counsel argued, admission of A.J.’s statements to Nurse Practitioner
    Haynes without A.J.’s testimony deprived the Defendant of the opportunity to confront
    his accuser and to present impeachment evidence.
    Appellate Issues
    In this appeal, the State contends that the trial court erred in ruling that A.J.’s
    statement to Nurse Practitioner Haynes would be excluded at the Defendant’s trial. The
    State argues that the statements were made for the primary purpose of medical diagnosis
    and treatment and were neither testimonial nor inadmissible hearsay. The State also
    argues that A.J.’s statements about the alleged offense, as recorded in her medical records
    created at the Children’s Advocacy Center, are admissible pursuant Tennessee Rule of
    Evidence 803(6), pertaining to the hearsay exception for business records. The State did
    not advance the latter theory of admissibility in the trial court. The Defendant contends
    that the trial court did not err in ruling that A.J.’s statements to Nurse Practitioner Haynes
    were inadmissible.
    Legal Principles
    Hearsay “is a statement, other than one made by the declarant while testifying at
    the trial or hearing, offered in evidence to prove the truth of the matter asserted.” Tenn.
    R. Evid. 801(c). Hearsay is inadmissible unless it qualifies as an exception. 
    Id. at 802.
    Tennessee Rule of Evidence 803(4) provides a hearsay exception for “[s]tatements made
    for purposes of medical diagnosis and treatment describing medical history; past or
    present symptoms, pain, or sensations; or the inception or general character of the cause
    or external source thereof insofar as reasonably pertinent to diagnosis and treatment.”
    The Confrontation Clause provides a criminal defendant the right to confront and
    cross-examine witnesses. See U.S. Const. amends. VI, XIV; Tenn. Const. art. I, ' 9;
    State v. Williams, 
    913 S.W.2d 462
    , 465 (Tenn. 1996). In State v. McCoy, 459 S.W.1, 13-
    14 (Tenn. 2014), our supreme court said that Article I, section 9 of the Tennessee
    Constitution placed no additional restrictions on the admission of hearsay statements
    beyond the limits of the federal constitution, as explained in Crawford v. Washington,
    
    541 U.S. 36
    , 59 (2004). Thus, the same standards apply in interpreting a defendant’s
    -6-
    confrontation rights under the state and federal constitutions. See State v. Hutchison, 
    482 S.W.3d 893
    , 905) (Tenn. 2016). In analyzing whether an out-of-court statement is barred
    by the Confrontation Clause, inquiry begins with “whether the challenged statement is
    testimonial.” See id.; State v. Dotson, 
    450 S.W.3d 1
    , 63 (Tenn. 2014). The
    Confrontation Clause has no bearing on the admission of statements which are
    nontestimonial hearsay. 
    Hutchison, 482 S.W.3d at 905-06
    (citing Davis v. Washington,
    
    547 U.S. 813
    , 823-24 (2006)); 
    Dotson, 450 S.W.3d at 63
    . Thus, the admissibility of a
    nontestimonial statement is determined by the traditional rules regarding the admission of
    hearsay evidence. State v. Cannon, 
    254 S.W.3d 287
    , 303 (Tenn. 2008); see 
    Davis, 547 U.S. at 821
    .
    A precise definition of what constitutes a testimonial statement has proven elusive.
    See, e.g., Williams v. Illinois, 
    132 S. Ct. 2221
    (2012) (proposing, in a plurality and two
    separate opinions, three methods for determining whether a statement is testimonial);
    
    Dotson; 450 S.W.3d at 68-70
    (noting the difficulty of discerning a cohesive, narrow rule
    from the fractured opinions of the Williams court).          Recently, our supreme court
    analyzed Williams and prescribed a framework for determining which evidence is
    testimonial. See 
    Dotson, 450 S.W.3d at 69
    . In this regard, a statement is testimonial “’if
    its primary purpose is evidentiary and it is either a targeted accusation or sufficiently
    formal in character.’” 
    Dotson, 450 S.W.3d at 69
    (quoting Young v. United States, 
    63 A.3d 1033
    , 1043-44 (D.C. 2013)); see 
    Hutchison, 482 S.W.3d at 910
    .
    In determining what statements are testimonial, our supreme court has also looked
    to the examples provided by Crawford:
    Various formulations of this core class of “testimonial” statements exist:
    “ex parte in-court testimony or its functional equivalent–that is, material
    such as affidavits, custodial examinations, prior testimony that the
    defendant was unable to cross-examine, or similar pretrial statements that
    declarants would reasonably expect to be used prosecutorially,”
    “extrajudicial statements . . . contained in formalized testimonial materials,
    such as affidavits, depositions, prior testimony, or confessions,”
    “statements that were made under circumstances which would lead an
    objective witness reasonably to believe that the statement would be
    available for use at a later trial.” These formulations all share a common
    nucleus and then define the Clause’s coverage at various levels of
    abstraction around it. Regardless of the precise articulation, some
    statements qualify under any definition—for example, ex parte testimony at
    a preliminary hearing.
    -7-
    
    Hutchison, 482 S.W.3d at 906
    (quoting 
    Crawford, 541 U.S. at 51-52
    ).
    In order for a testimonial statement to be admissible, the declarant must be
    unavailable to testify, and the defendant must have had a prior opportunity to cross-
    examine the declarant.        
    Crawford, 541 U.S. at 53-55
    ; see Melendez-Diaz v.
    Massachusetts, 
    557 U.S. 305
    , 309 (2009). However, the Confrontation Clause is not
    implicated when testimonial statements are not used to show the truth of the matter
    asserted. 
    Crawford, 541 U.S. at 59
    n.9. Similarly, no Confrontation Clause violation
    occurs if the declarant is called as a trial witness and is subject to cross-examination
    regarding the declarant’s prior testimonial statements. See 
    Dotson, 450 S.W.3d at 73
    ; see
    also 
    Crawford, 541 U.S. at 59
    , n.9; California v. Green, 
    399 U.S. 149
    , 162 (1970).
    Trial Court’s Ruling
    In its order, the trial court stated:
    From the proof, lack of proof, and argument in this case, the Court
    gathers:
    (1) that the alleged victim was twelve at the time of the forensic
    examination and is sixteen now;
    (2) that the alleged victim and her mother did not seek diagnosis or
    treatment on their own;
    (3) that, as part of their investigation, police referred the alleged
    victim for a forensic examination;
    (4) that, although the forensic examiner was the first health-care
    provider to examine the alleged victim after her report, apparently, the
    alleged victim was not complaining of any physical or mental condition
    necessitating diagnosis or treatment apart from the reported events, at least
    some of which were remote in time, and there was no ongoing emergency;
    (5) that the forensic examiner, who used the term “forensic” to
    describe her role or the examination, had a role in the police investigation,
    sharing what she learned, observed, or collected with police or other law
    enforcement agencies, presumably, with the alleged victim’s or her
    mother’s consent; and
    -8-
    (6) that, although the forensic examiner administered unspecified
    treatment, there is no evidence that the perpetrator’s identity was a factor in
    the treatment.
    From these circumstances, the Court concludes that the examination had
    dual purposes and that the primary purpose was testimonial.
    The court noted that although some cases had discussed dissecting testimonial and non-
    testimonial components of a statement, such an approach was not appropriate in the
    present case because A.J.’s statement was not in evidence. The court found that at the
    time of the forensic examination, the Defendant was the target of the investigation. From
    its findings, the court concluded that the Confrontation Clause barred the State from
    presenting Nurse Practitioner Haynes’s testimony about the victim’s statements regarding
    the alleged offense.
    The trial court went on to examine the applicability of Tennessee Rule of
    Evidence 803(4) and stated the following:
    While the Court agrees with the state that Rule 803 does not condition the
    hearsay exceptions that it recognizes on the availability or unavailability of
    the declarant, the application of hearsay exceptions is subject to
    constitutional considerations that do depend on the availability or
    unavailability of a declarant. Those constraints preclude admission of the
    statement in issue pursuant to Rule 803(4).
    Standards of Review
    A trial court’s factual findings and credibility determinations relative to a hearsay
    issue are binding upon an appellate court unless the evidence preponderates against them.
    Kendrick v. State, 
    454 S.W.3d 450
    , 479 (Tenn. 2015). The determination of whether the
    statement in question is hearsay and whether a hearsay exception applies are questions of
    law that are reviewed de novo. 
    Id. A question
    of whether a defendant’s right of
    confrontation is violated by the admission of evidence is one of law, which we review de
    novo. See, e.g., State v. McCoy, 
    459 S.W.3d 1
    , 8 (Tenn. 2014).
    Analysis
    As we have stated, the trial court found that, as a function of the law enforcement
    investigation, the police referred A.J. to the Children’s Advocacy Center for a forensic
    examination, that A.J. and her mother did not seek medical treatment independently, that
    -9-
    no ongoing emergency existed, that Nurse Practitioner Haynes was a participant in the
    police investigation because she shared the information she obtained with the police, and
    that, although treatment was prescribed, no evidence showed that the alleged
    perpetrator’s identity was a factor in the treatment provided. From these findings, the
    court concluded that the primary purpose of A.J.’s statement, as recounted in Nurse
    Practitioner Haynes’s testimony at the hearing on the motion in limine, was testimonial.
    As Hutchison outlines, testimonial and nontestimonial statements are
    distinguished by examining the primary purpose of the statement. 
    Id. (relying on
    Davis,
    547 U.S. at 822
    ). In this regard, Davis provides:
    Statements are nontestimonial when made in the course of police
    interrogation under circumstances objectively indicating that the primary
    purpose of the interrogation is to enable police assistance to meet an
    ongoing emergency. They are testimonial when the circumstances
    objectively indicate that there is no such ongoing emergency, and that the
    primary purpose of the interrogation is to establish or prove past events
    potentially relevant to later criminal prosecution.
    
    Davis, 547 U.S. at 822
    ; see 
    Hutchison, 482 S.W.3d at 906
    .
    Nurse Practitioner Haynes testified to her understanding that A.J. had been
    referred to the center by the police or DCS. Although the State argues on appeal that
    Nurse Practitioner Haynes’s testimony was based upon an assumption regarding how A.J.
    was directed to the Children’s Advocacy Center, the intake paperwork completed by
    A.J.’s mother reflects that A.J. was referred to the center by the Chattanooga Police
    Department.
    The medical records also state that “the purpose” of the examination was “to
    collect evidence and document trauma, if present.” The records also indicate that the
    medical evaluation holds potential evidentiary value relative to claimed abuse and that
    the examiner planned to communicate with a police detective the same day. The patient
    instructions included a directive to call the detective with questions or concerns.
    According to the evidence presented at the hearing, A.J. received a pregnancy test
    and was provided with prophylaxis against pregnancy and sexually transmitted
    infections. Nurse Practitioner Haynes testified that her questioning A.J. about the alleged
    incident was necessary in order to determine the nature of the examination and the
    necessary treatment.
    -10-
    In reviewing the trial court’s ruling in the present case, we are mindful of our
    supreme court’s decision in Cannon, in which the victim called 9-1-1 immediately after
    the assault and was taken by ambulance to an emergency room, where she made
    statements that the she had been raped and received treatment for multiple physical
    injuries. 
    Cannon, 254 S.W.3d at 293
    . The victim did not testify at the trial. The
    Tennessee Supreme Court deemed her statements to emergency room personnel to be
    nontestimonial because they “were objectively for the primary purpose of seeking
    medical diagnosis and treatment for injuries sustained in the attack.” 
    Id. at 304.
    The
    victim had also made statements to a police officer at the emergency room, and the court
    deemed these statements to be testimonial because they were objectively made to
    describe and establish a past crime and were not to enable the officer to respond to an
    ongoing emergency. 
    Id. After the
    victim had been examined and treated by emergency
    room personnel, she made statements to a Sexual Assault Crisis Center nurse, who
    questioned the victim with a detective. The nurse also performed a physical examination
    of the victim. The court categorized the victim’s statements to the nurse as testimonial
    because the statements were not reasonably pertinent to medical diagnosis and treatment
    and were, instead, made for the primary purpose of showing past events with potential
    relevance to a prosecution. 
    Id. at 304-05.
    Upon review, we conclude that the evidence does not preponderate against the
    trial court’s finding that the primary purpose of the questioning and examination which
    yielded A.J.’s statement was to gather evidence of the alleged offense for possible use in
    a future prosecution. A.J. and her mother did not go to the Children’s Advocacy Center
    on their own seeking medical treatment. Rather, they went there at the direction of the
    police. Nurse Practitioner Haynes and the police consulted while the victim was at the
    Children’s Advocacy Center because the record reflects that the police were involved in
    the decision to administer a rape kit and that the police received the completed rape kit
    and information about the findings of the examination. The evidence does not show that
    A.J. presented with any physical injuries requiring immediate medical treatment. Rather,
    A.J. sought treatment the day after the alleged incident, which was also the day after A.J.
    first reported the alleged abuse. A.J.’s statements provided Nurse Practitioner Haynes
    with information for determining the course of the examination, the purpose of which,
    according to the medical records, was to gather evidence. Although the record
    demonstrates that the victim received prophylactic treatment to prevent pregnancy and
    sexually transmitted infections, that she received reassurance that her “body is okay,” and
    that counseling was recommended, the trial court concluded that these purposes were
    secondary.
    The trial court’s findings, in turn, support its conclusion that A.J.’s statement was
    testimonial and barred by the Confrontation Clause. See 
    Davis, 547 U.S. at 822
    ;
    -11-
    
    Hutchison, 482 S.W.3d at 906
    . As we have noted, the State does not intend to call A.J. as
    a trial witness but acknowledges that she is not “unavailable” as a witness. Testimonial
    hearsay is inadmissible unless the declarant is called as a witness and the defendant is
    afforded the opportunity to cross-examine the declarant regarding the prior statement.
    See 
    Dotson, 450 S.W.3d at 73
    ; see also 
    Crawford, 541 U.S. at 59
    , n.9; 
    Green, 399 U.S. at 162
    ; State v. Franklin, 
    308 S.W.3d 799
    , 809-10 (Tenn. 2010) (stating that the
    admissibility of testimonial hearsay is subject to Confrontation Clause scrutiny, whereas
    the admissibility of nontestimonial hearsay is governed by the Tennessee Rules of
    Evidence). Given the testimonial nature of the evidence and the lack of a showing of
    A.J.’s unavailability, the trial court did not err in determining that the Confrontation
    Clause precluded admission of the evidence, and that, as a result, the hearsay exception
    provided by Tennessee Rule of Evidence 803(4) is unavailable as a means for admitting
    this evidence.
    The State also argues that the evidence of A.J.’s statement is admissible via her
    medical records pursuant to Rule of Evidence 803(6), the hearsay exception for records
    of regularly conducted activity. This theory was advanced in the State’s application to
    this court for an interlocutory appeal but was not advanced in the trial court at the hearing
    on the motion in limine. Rule 803(6) permits evidence of “opinions and diagnoses,”
    provided the foundational requirements are met. See Tenn. R. Evid. 803(6). To the
    extent that the records document A.J.’s statements, an issue of “hearsay within hearsay”
    exists, and the evidence is admissible provided each component of the combined
    statements fits within an exception to the rule against hearsay. See Tenn. R. Evid. 805.
    The concern in this appeal is A.J.’s statements about the alleged offense. To the extent
    that these statements are documented in the medical records, the trial court found that the
    primary purpose of these statements was “to establish or prove past events potentially
    relevant to later criminal prosecution” and that, therefore, they were testimonial. See
    
    Davis, 547 U.S. at 822
    ; 
    Hutchison, 482 S.W.3d at 906
    . Thus, it is of no consequence
    whether the evidentiary source of information is Nurse Practitioner Haynes’s testimony
    or A.J.’s medical records. In the absence of a showing that A.J. is unavailable as a trial
    witness and that she was subjected to cross-examination, the Confrontation Clause bars
    admission of her statements to Nurse Practitioner Haynes via the medical records
    pursuant to Rule 803(6). See 
    Dotson, 450 S.W.3d at 73
    ; see also 
    Crawford, 541 U.S. at 59
    , n.9; 
    Green, 399 U.S. at 162
    .
    In reaching this conclusion, we have considered the State’s citation to State v.
    Howard, 
    504 S.W.3d 260
    , 277-80 (Tenn. 2016), a case involving the admission of
    records from the Hamilton County Children’s Advocacy Center pursuant to Tennessee
    Rule of Evidence 803(6). The supreme court considered the issue of “hearsay within
    hearsay” relative to the victims’ statements about the offenses, as documented in the
    -12-
    records. The trial court determined, based upon the facts presented at an evidentiary
    hearing, that the victims’ statements had been made for the purpose of medical diagnosis
    and treatment, and the supreme court determined that the record supported the trial
    court’s factual findings. See 
    Howard, 504 S.W.3d at 280
    . Significantly, however, the
    supreme court noted that no Confrontation Clause issue existed because the victims
    testified at the trial and were subject to cross-examination about their statements as
    documented in the records. 
    Id. Thus, Howard
    is inapposite to the present case, in which
    the Confrontation Clause issue is paramount because the State does not intend to call A.J.
    as a witness.
    We have also considered State v. Dean, 
    76 S.W.3d 352
    , 365 (Tenn. Crim. App.
    2001), in which this court rejected the defendant’s claim that the trial court had
    improperly admitted records from a rape victim’s emergency room examination by a
    nurse employed by a sexual assault center, pursuant to Tennessee Rule of Evidence
    803(6). The Dean defendant raised two issues relative to the admission of the evidence:
    (1) whether the nurse qualified as a “keeper” of the records and (2) whether the records
    were prepared for the purpose of litigation. 
    Dean, 76 S.W.3d at 365
    . Significantly, the
    defendant did not raise a challenge to any statements made by the victim that were
    documented in the records, nor did he raise a Confrontation Clause challenge relative to
    the records. See 
    id. The victim
    in Dean testified at the trial. 
    Id. at 357-58.
    Like
    Howard, Dean is not instructive because no Confrontation Clause issue existed.
    Finally, we address the alternative theory advanced by the State in its oral
    argument in this court that the substance of A.J.’s statement about the alleged assault, but
    not her identification of the alleged perpetrator, is admissible. We are unpersuaded. The
    trial court considered the hearing evidence and determined that A.J.’s statements to Nurse
    Practitioner Haynes about the alleged assault were made in circumstances which made
    them testimonial in that they tended “to establish or prove past events potentially relevant
    to later criminal prosecution.” See 
    Davis, 547 U.S. at 822
    ; 
    Hutchison, 482 S.W.3d at 906
    . Excising A.J.’s identification of the alleged perpetrator does not change the
    character of her statements about the events which comprised the alleged offense.
    In consideration of the foregoing and the record as a whole, the order of the trial
    court is affirmed.
    _____________________________________
    ROBERT H. MONTGOMERY, JR., JUDGE
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