State v. Burke ( 2021 )

FILE THIS OPINION WAS FILED
FOR RECORD AT 8 A.M. ON
IN CLERK’S OFFICE JANUARY 14, 2021
SUPREME COURT, STATE OF WASHINGTON
JANUARY 14, 2021
SUSAN L. CARLSON
SUPREME COURT CLERK
IN THE SUPREME COURT OF THE STATE OF WASHINGTON
STATE OF WASHINGTON, ) No. 96783-1
)
Petitioner, )
)
v. ) EN BANC
)
RONALD DELESTER BURKE, )
) Filed: January 14, 2021
Respondent. )
______________________________ )
MONTOYA-LEWIS, J.—The Sixth Amendment guarantees that “[i]n all
criminal prosecutions, the accused shall enjoy the right . . . to be confronted with the
witnesses against [them].” U.S. CONST. amend. VI. The confrontation clause is
concerned with “‘witnesses’ against the accused,” meaning those who “‘bear
testimony.’” Crawford v. Washington, 541 U.S. 36, 51, 124 S. Ct. 1354, 158 L. Ed.
2d 177 (2004) (quoting 2 NOAH WEBSTER, AN AMERICAN DICTIONARY OF THE
ENGLISH LANGUAGE (1828)). A person accused of committing a crime has a right to
be confronted by those who bear testimony against them. Thus, statements that are
made out of court that are testimonial cannot be admitted for use against a criminal
State v. Burke
No. 96783-1
defendant unless the speaker is unavailable and the defendant had a prior opportunity
for cross-examination. Davis v. Washington, 547 U.S. 813, 821, 126 S. Ct. 2266,
165 L. Ed. 2d 224 (2006) (quoting and citing Crawford, 541 U.S. at 53-54, 51). On
the other hand, statements that are not testimonial do not implicate the confrontation
clause. Id. To determine whether a statement is testimonial, we must identify its
primary purpose. State v. Scanlan, 193 Wn.2d 753, 766, 445 P.3d 960 (2019)
(quoting Ohio v. Clark, 576 U.S. 237, 245, 135 S. Ct. 2173, 192 L. Ed. 2d 306(2015)), cert. denied, 140 S. Ct. 834 (2020).
In this case, a patient being treated for a sexual assault made statements to a
sexual assault nurse examiner in the course of an exam with both medical and
forensic purposes. We hold that under these circumstances, the primary purpose of
nearly all of the statements was to guide the provision of medical care, not to create
an out-of-court substitute for trial testimony. Thus, the statements were not
testimonial, so their admission did not violate the Sixth Amendment. We further
hold that the trial court did not abuse its discretion in admitting those statements
under the hearsay exception for statements made for purposes of medical diagnosis
or treatment. Finally, we hold that the trial court did err in admitting one statement
describing the assailant, but the error was harmless. Accordingly, we reverse.
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I. FACTS AND PROCEDURAL HISTORY
A. Factual Background
Around 1:30 a.m. on July 3, 2009, K.E.H. arrived in the emergency
department at Tacoma General Hospital. She reported that she had just been raped
in nearby Wright Park, where she resided. She was crying and had leaves and grass
in her hair. Shortly after she arrived, a social worker called the police to report the
rape. Around 3:15 a.m., Officer Khanh Phan arrived at the Tacoma General
emergency department and interviewed K.E.H. about the incident. K.E.H. gave a
description of the assailant and the location of the assault. After interviewing her,
Officer Phan went to the park to look for evidence and possible witnesses or suspects
but found no one.
K.E.H. was treated in the emergency department, where she received a CT
(computed tomography) scan and blood and urine tests. At about 11:15 a.m., K.E.H.
was medically cleared by the emergency department to go on to the sexual assault
exam. Sexual assault nurse examiner Kay Frey conducted K.E.H.’s sexual assault
exam that afternoon.
DNA (deoxyribonucleic acid) testing revealed spermatozoa on K.E.H.’s
underwear that had been collected during the sexual assault exam. In 2011, police
matched the DNA on the underwear to Ronald Burke. Burke lived in an apartment
near Wright Park in Tacoma in 2009 and admitted to having been to the park.
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However, he denied ever having sex there or getting in a fight with a woman there.
In 2014,1 Burke was charged with second degree rape by forcible compulsion.
K.E.H. died in 2011.
B. Procedural History
Burke was tried by a jury in 2016. The State sought to admit statements K.E.H.
made to Nurse Frey during the sexual assault examination, relying on the hearsay
exception for statements made for purposes of medical diagnosis or treatment. ER
803(a)(4). Burke objected to their admission, contending that the statements were
testimonial, so their admission would violate his Sixth Amendment right to
confrontation. The court held a hearing on the admissibility of the statements,
ultimately ruling that all of the statements qualified as statements for the purpose of
medical diagnosis or treatment under ER 803(a)(4) and that they were
nontestimonial for purposes of the confrontation clause.
1. Hearing on Admissibility of the Statements
At the hearing, Nurse Frey testified that she was a nurse practitioner and that
in 2009 she was working as a sexual assault nurse examiner at Tacoma General,
where she provided forensic evaluations and medical care for patients who were
victims of sexual assault. She recalled that on July 3, 2009, she arrived at the Tacoma
1
At the time Burke was identified as a suspect in this case, he was incarcerated for a
separate offense, and police waited until his appeal for that offense was exhausted before charging
him with the rape of K.E.H.
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General emergency department around 7:00 a.m. to see another patient. When she
met K.E.H., Nurse Frey said that she would not be able to see K.E.H. for some time
because she needed to see the other patient first, and K.E.H. said she wanted to wait.
In the notes from the examination, Nurse Frey indicated that K.E.H. had waited for
several hours while Nurse Frey was with another patient “because I don’t want him
to be out there doing this to someone else.” Pretrial Mot. Ex. 19F. Nurse Frey began
K.E.H.’s examination around 4:00 p.m. that day.
Describing her duties as a sexual assault nurse examiner, Nurse Frey
explained that she would respond to calls from emergency departments “for
patients[2] who had presented there with a history of sexual assault, and we went out
to whichever hospital called . . . and did the forensic evaluations and medical care
for them.” 6 Verbatim Transcript of Proceedings (VTP) (Nov. 3, 2016) at 543. She
also testified about the purpose of the exam she performed on K.E.H.:
The purposes are to do the forensic piece: Photographing, taking a
history, doing any DNA retrieval that could be done. Another purpose
is to provide them with the medical care they need, subsequent to their
assault, and provide support and connections for them via advocates
and social workers and that kind of thing. So it’s to basically manage
their case.
Id. at 545. Nurse Frey consulted the documents that comprised the sexual assault
evaluation, which the court admitted for the purposes of the hearing.
2
We note here she describes those for whom she provides these services as “patients,” not
“witnesses.”
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The sexual assault exam began with a consent form, which K.E.H. signed.
The consent form indicated under the “Medical Care” heading that “[a] medical
screening examination and care must be provided by an emergency department or
primary care provider prior to the forensic evaluation. A forensic evaluation does
not include general medical care.” Pretrial Mot. Ex. 19B. Nurse Frey explained that
this meant patients needed to be “deemed capable of going forward” before
beginning the sexual assault exam, where she would provide medication and
treatment specific to sexual assault. 6 VTP (Nov. 3, 2016) at 555, 557. Under the
heading “Forensic Evaluation,” the consent form indicated that physical evidence,
such as swabs and blood, may be collected; photographs may be taken and used for
legal purposes; medication may be recommended (“including immunizations, anti-
nausea medications, emergency contraception and medications to treat sexually
transmitted infections”); the forensic nurse examiner may speak to the investigating
officer only if the assault had been reported to law enforcement; and the detailed
medical records (“photographs, lab results, written documentation”) would be kept
confidential. Pretrial Mot. Ex. 19B (emphasis omitted). Under the heading “Physical
Evidence Disposition,” the consent form indicated that all physical evidence
collected during the forensic evaluation (“sexual assault kit, clothing”) would be
released to the agency investigating or prosecuting the assault. Id. (emphasis
omitted).
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After obtaining K.E.H.’s consent to perform the exam, Nurse Frey took
K.E.H.’s patient history, which she recorded “word for word” on the forensic
evaluation patient narrative. 6 VTP (Nov. 3, 2016) at 549. Nurse Frey testified that
the patient history is
probably the most important thing.
....
. . . Well, this is just medical training in general. History guides
everything, and that’s true for sexual assault patients as well. So what
they tell you, what they can tell you, what they aren’t able to tell you,
directs you further to what they might need, medically to figure it out.
....
. . . Sometimes it governs medications, for example. Sometimes it
governs where you might look for injuries more closely; that kind of
thing.
Id. at 545-46. When Nurse Frey asked K.E.H. what happened in Wright Park, K.E.H.
responded:
I was sitting there rolling myself a cigarette. I know he covered my
mouth because I would have been screaming for help. I was taken to
the ground. I don’t know if he tried choking me or not. The next thing
I knew I was taken to the ground, my pants were off and stuff and he
was inside me. It was over and done with. I think he told me to keep
my mouth shut. That’s all I remember, then I came here. I walked over
to the hospital.
Pretrial Mot. Ex. 19E; 6 VTP (Nov. 3, 2016) at 612 (Nurse Frey reading K.E.H.’s
response from Pretrial Mot. Ex. 19E during the hearing).
Next, Nurse Frey asked K.E.H. specific questions about what she remembered
from the assault, according to the patient history protocol. In the patient history
forms, she recorded quoted language from K.E.H. describing the location of the
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assault (“close to 6th Avenue [at] a table”) and the assailant’s appearance (“He was
tall, a light black, no hair or short hair. He had a white T-shirt and jeans. No jacket.”).
Pretrial Mot. Ex. 19C. Nurse Frey also recorded K.E.H.’s answers to questions about
penetration, ejaculation, contraception, and her position during the assault (“on the
ground on my back”). Id. The patient history forms also included K.E.H.’s answers
to questions about strangulation (“He put his hand over my mouth.”), grasping,
grabbing, or holding (“He was laying on me.”), intimidation or threat (“To keep my
mouth shut & don’t report it.”), and her pain level, allergies, and postassault hygiene.
Pretrial Mot. Ex. 19D. The forms also indicated that K.E.H. was allergic to some
pain medications and needed crutches due to arthritis. Nurse Frey testified that the
answers to these questions would guide her to look for injuries as well as evidence. 3
Nurse Frey conducted a general exam and a genital exam, and took photos of
and documented K.E.H.’s injuries on the evaluation form. Nurse Frey clarified that
while the emergency department provided K.E.H. with general medical care, she
provided medications and treatment specifically relating to the sexual assault. She
testified that when she examined K.E.H., she discovered a cervical laceration, an
unusual injury, that was still bleeding. She was the first medical provider to discover
3
Nurse Frey explained some of the routine and specific treatment she provided during
sexual assault exams. For example, she explained that she would prescribe standard medications
to most sexual assault patients, but an assault that involved strangulation would trigger specific
treatment.
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that injury, and she was concerned that it might require further treatment by an
obstetrician-gynecologist.
Finally, Nurse Frey explained that although sexual assault forensic exams are
paid for by state and federal crime victims’ funds, her salary was paid by the health
care organization MultiCare and she did not take any direction from law enforcement
regarding the steps she should take in her job. Nurse Frey recalled that K.E.H. had
been visited by law enforcement because she wanted to report the rape, but Nurse
Frey herself did not meet with law enforcement “in any way” on this case, and no
member of law enforcement was present during the exam. 6 VTP (Nov. 3, 2016) at
548.
The court ruled K.E.H.’s statements admissible. Nurse Frey was permitted to
testify to the jury about the statements K.E.H. made to her in the course of the sexual
assault examination and evaluation.
2. Trial Testimony
Before the jury, Nurse Frey testified about her examination of K.E.H. She read
K.E.H.’s descriptions of the assault, the location, and the assailant aloud to the jury.
She also read K.E.H.’s answers to the targeted questions about penetration,
ejaculation, contraception, her position during the assault, and her pain level. She
read K.E.H.’s answers about strangulation, grabbing, grasping, or holding, and
intimidation as well. She described the injuries she observed during the general
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physical exam and the genital exam, including injuries to K.E.H.’s knee, elbow,
inner thigh, and internal and external genitalia, and the more serious cervical
laceration.
Several police officers testified about the process of identifying Burke as a
suspect. A social worker had called the police when K.E.H. arrived at Tacoma
General, reporting that K.E.H. had been raped. Officer Phan testified that he
interviewed K.E.H. in the early hours of the morning on July 3, 2009. He took her
description of the assault and the assailant, and he went to the park to look for anyone
fitting that description, but he did not find anyone at all. Detective Christie Yglesias
testified that the initial police report contained “a general description [of the
assailant], but nothing that would stick out.” 8 VTP (Nov. 8, 2016) at 864. She said
that initial testing of the sexual assault kit in 2009 revealed a DNA profile, but no
matches were found in the crime lab database, and the case remained active, pending
further investigation.
Detective Yglesias testified that in May 2011, the crime lab obtained a match
between Burke and the DNA profile found on K.E.H.’s underwear. Police obtained
a reference DNA sample from Burke to compare with the sample from the sexual
assault kit. Forensic DNA analyst Dr. Kelli Byrd testified extensively about the
process of testing and matching the DNA in this case. The forensic lab identified
spermatozoa on the underwear in the sexual assault kit. It found that Burke could not
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be excluded as a contributor to the DNA from the sample and that the chances of
someone else matching the sample to the degree Burke matched were 1 in 170
quadrillion.4
The jury found Burke guilty of rape in the second degree by forcible
compulsion. The trial court imposed legal financial obligations in the judgment and
sentence, although it found that Burke was indigent and would not be able to pay
nonmandatory fines or costs. It ordered him to pay restitution and a crime victim
assessment, as well as a $100 DNA collection fee and a $200 criminal filing fee,
with interest to accrue on the legal financial obligations.
Burke appealed. He argued that (1) K.E.H.’s statements to Nurse Frey were
testimonial, so their admission violated his right to confrontation, and (2) the
statements did not qualify as statements made for the purpose of medical diagnosis
under ER 803(a)(4). Although Scanlan, 193 Wn.2d at 761, had not yet been decided,
the Court of Appeals applied the primary purpose test for the confrontation clause
issue, as articulated in Clark, 576 U.S. at 244-46, and Davis, 547 U.S. at 822. State
v. Burke, 6 Wn. App. 2d 950, 953, 431 P.3d 1109 (2018). The Court of Appeals held
that all of K.E.H.’s statements to Nurse Frey were testimonial, their admission
violated the confrontation clause, and the error was not harmless. Id. Burke had also
4
Burke did not challenge the DNA evidence or any testimony other than Nurse Frey’s on
appeal.
11
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sought to have certain legal financial obligations stricken from the judgment and
sentence. The State agreed that Burke was indigent and that his DNA had been
previously collected as a result of a prior conviction, so the DNA collection fee, the
criminal filing fee, and the interest provision should be stricken. However, because
the Court of Appeals reversed on the confrontation clause issue, it did not reach the
ER 803(a)(4) or legal financial obligation issues. Id. at 973 & n.9.
The State sought this court’s review, which we granted. 194 Wn.2d 1009(2019).
II. ANALYSIS
A. Confrontation Clause
The Sixth Amendment provides that “[i]n all criminal prosecutions, the
accused shall enjoy the right . . . to be confronted with the witnesses against him.”
U.S. CONST. amend. VI. 5 The confrontation clause prohibits the admission of
testimonial statements unless the declarant is unavailable and the defendant had a
5
See also Pointer v. Texas, 380 U.S. 400, 403, 85 S. Ct. 1065, 13 L. Ed. 2d 923 (1965)
(incorporating the confrontation clause to the states). Burke refers to the right to confrontation
contained in both the Sixth Amendment to the United States Constitution and article I, section 22
of the Washington Constitution. However, he fails to present an independent analysis of the right
under our state constitution. Therefore, our analysis is limited to the federal constitution. See
Scanlan, 193 Wn.2d at 773-74 (Gordon McCloud, J., concurring); see also Burke, 6 Wn. App. 2d
at 963 n.2.
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prior opportunity for cross-examination. Crawford, 541 U.S. at 59. Review of
confrontation clause challenges is de novo. Scanlan, 193 Wn.2d at 761.
Only statements that are testimonial implicate the confrontation clause. Davis,
547 U.S. at 821. The confrontation clause speaks to “‘witnesses’ against the
accused,” meaning those who “‘bear testimony,’” which is “‘[a] solemn declaration
or affirmation made for the purpose of establishing or proving some fact.’”
Crawford, 541 U.S. at 51 (alteration in original) (quoting 2 WEBSTER, supra).
Declining to define the precise scope of “testimonial” statements, the Crawford
Court explained that “it applies at a minimum to prior testimony at a preliminary
hearing, before a grand jury, or at a former trial[,] and to police interrogations.” Id.
at 68.
In the years following Crawford, the United States Supreme Court articulated
what became known as the primary purpose test to determine whether out-of-court
statements are testimonial.6 In Davis, the Court explained that statements “are
testimonial when the circumstances objectively indicate that . . . the primary purpose
of the interrogation is to establish or prove past events potentially relevant to later
criminal prosecution.” 547 U.S. at 822. The primary purpose test applies to all
statements that implicate the confrontation clause, regardless of to whom they are
made. Scanlan, 193 Wn.2d at 763-66; see, e.g., id. at 766 (medical providers); Clark,
6
See Scanlan, 193 Wn.2d at 761-66, for a review of the origins of this test.
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576 U.S. at 246 (preschool teachers); State v. Beadle, 173 Wn.2d 97, 109-10, 265
P.3d 863 (2011) (law enforcement).
Courts must determine the primary purpose of an interrogation “by
objectively evaluating the statements and actions of the parties to the encounter, in
light of the circumstances in which the interrogation occurs.” Michigan v. Bryant,
562 U.S. 344, 370, 131 S. Ct. 1143, 179 L. Ed. 2d 93 (2011). When the primary
purpose of questioning is to respond to an ongoing emergency, for example, “its
purpose is not to create a record for trial and thus is not within the scope of the
Clause. But there may be other circumstances, aside from ongoing emergencies,
when a statement is not procured with a primary purpose of creating an out-of-court
substitute for trial testimony.” Id. at 358. Thus, to determine whether the primary
purpose of the statements is to create an out-of-court substitute for trial testimony,
we must objectively evaluate the statements and actions of both the declarant and
the individual who hears the statements in light of the circumstances in which their
conversation occurred.
Statements are testimonial when they are made to establish past facts in order
to investigate or prosecute a crime. For example, statements are testimonial when
they are made in formal police interrogations. See Crawford, 541 U.S. at 52. Less
formal statements to police officers can also be testimonial. Statements to police
responding to a 911 call were testimonial when the declarant described past events
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in the presence of police officers in order to help them investigate a crime and it was
clear the declarant was in no immediate danger. See Davis, 547 U.S. at 829-30; State
v. Koslowski, 166 Wn.2d 409, 430, 209 P.3d 479 (2009). Similarly, statements that
a victim of child molestation made to police were testimonial when the interview
took place months after the abuse had ended and the perpetrator had been removed
from the home. Beadle, 173 Wn.2d at 109-10. Although a Child Protective Services
(CPS) worker was present during the interview, the immediate danger to the
declarant had passed. Id. The CPS worker was “present only to assist the police
department” in obtaining evidence from a traumatized child—“not to protect [the
child’s] welfare in her capacity as a CPS employee”—and the primary purpose of
the statements was to establish or prove past facts for use in a criminal prosecution.
Id.On the other hand, statements are nontestimonial when they have another
primary purpose. Statements made to assist police in addressing an ongoing
emergency is a well-established nontestimonial purpose. For example, frantic
statements to a 911 emergency operator describing the identity of an assailant in a
domestic disturbance in progress were nontestimonial because the declarant was
seeking help in the face of immediate danger. Davis, 547 U.S. at 827. Statements
made by a man bleeding from a gunshot wound, describing the shooter and the
location of the shooting to police responding to radio dispatch, were nontestimonial
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because there was an ongoing emergency endangering the public at large. Bryant,
562 U.S. at 374-78.
The role of the person the declarant is speaking to is significant to determining
the primary purpose of a statement. Clark, 576 U.S. at 249 (“Courts must evaluate
challenged statements in context, and part of that context is the questioner’s
identity.”). A person “who makes a formal statement to government officers bears
testimony in a sense that a person who makes” statements in other contexts does not.
Crawford, 541 U.S. at 51. Law enforcement officers are “principally charged with
uncovering and prosecuting criminal behavior”; thus, statements made to them are
much more likely to be used as a substitute for trial testimony. Clark, 576 U.S. at
249. Additionally, a person conducting an interrogation for the police may be
considered an agent of the police for purposes of the confrontation clause. See, e.g.,
Davis, 547 U.S. at 823 n.2. 7
Statements made to witnesses other than law enforcement officers are far
more likely to be made for reasons not primarily associated with criminal
prosecution. Statements are nontestimonial when their primary purpose is to guide
the provision of medical care or to determine whether a person responsible for the
7
Without deciding whether the acts of 911 operators are in fact acts of police, the Davis
Court analyzed statements made to a 911 operator as statements made to law enforcement
personnel, reasoning that “[i]f 911 operators are not themselves law enforcement officers, they
may at least be agents of law enforcement when they conduct interrogations of 911 callers.” 547
U.S. at 823 n.2.
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declarant’s safety should permit them to leave. For example, a child’s statement to
his preschool teacher describing abuse and his abuser were nontestimonial because
the teacher needed to determine whether it was safe to release him to go home with
his guardian. Clark, 576 U.S. at 246-47. As we explained in Scanlan, statements to
medical providers “are ‘significantly less likely to be testimonial than statements
given to law enforcement officers’ because medical personnel are ‘not principally
charged with uncovering and prosecuting criminal behavior.’” Scanlan, 193 Wn.2d
at 767 (quoting Clark, 576 U.S. at 249). There, a domestic violence victim described
the cause of his injuries to emergency and follow-up medical providers. Id. at 758-
60. Those statements were nontestimonial because both sets of medical providers
needed to understand how to treat the injuries. Id. at 768. The victim’s statements
identifying his girlfriend as the assailant were similarly nontestimonial because the
medical providers needed to know whether he would be safe upon discharge. Id. at
768-69.
1. Nontestimonial Statements8
Objectively viewing the statements and actions of K.E.H. and Nurse Frey in
light of the circumstances of a sexual assault exam, we hold that nearly all of
K.E.H.’s statements were nontestimonial. A sexual assault exam contains both
8
For purposes of determining whether the statements were admissible, the facts are limited
to those presented at the admissibility hearing.
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forensic and medical purposes, and some statements may be more relevant to one
purpose than another. However, the confrontation clause requires us to identify a
singular dominant purpose to determine whether statements are testimonial. Davis,
547 U.S. at 822. Therefore, we must “objectively evaluate[] the statements and
actions of the parties to the encounter, in light of the circumstances in which the
interrogation occurs,” to determine the primary purpose of statements made to a
sexual assault nurse examiner. Bryant, 562 U.S. at 370. We hold that nearly all of
K.E.H.’s statements were nontestimonial because their primary purpose was to guide
the provision of medical care.
Nurse Frey’s role as a sexual assault nurse examiner requires us to determine
whether she was principally acting as a medical provider or as someone charged with
uncovering and prosecuting criminal behavior when she elicited these statements
from K.E.H. Scanlan, 193 Wn.2d at 767; Clark, 576 U.S. at 249. The role of sexual
assault nurse examiner shares features with both medical providers and law
enforcement because the nurse’s duties are to provide medical care and to collect
evidence. However, we do not believe that sexual assault nurse examiners are
“principally charged with uncovering and prosecuting criminal behavior.” Clark,
576 U.S. at 249 (emphasis added).9
9
Other jurisdictions have split on whether the connection to investigating officers or the
provision of medical care dictates the primary purpose of a forensic sexual assault exam in a
particular factual scenario. See State v. Hill, 236 Ariz. 162, 167, 336 P.3d 1283 (Ariz. Ct. App.
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Sexual assault nurse examiners are medical professionals with specialized
evidence-collecting skills and training that supplement their medical training.10 But
this specialization does not transform a class of medical professionals into agents of
the police, nor does it mean that their duty to provide medical care becomes a lower
priority than their evidence-collecting responsibilities. Sexual assault nurse
examiner programs emerged in the 1970s as “nurses, other medical professionals,
counselors, and advocates working with rape victims in hospitals, clinics, and other
settings . . . recognized that services to sexual assault victims were inadequate and
not at the same high standard of care for other [emergency department] clients.”
LINDA E. LEDRAY, SEXUAL ASSAULT RES. SERV., SEXUAL ASSAULT NURSE
2014) (“Because forensic medical examinations often have two purposes—to gather evidence for
a criminal investigation and to provide medical care to the victim—whether a victim’s statement
in response to a question by the examiner is testimonial for purposes of the Confrontation Clause
turns on whether the surrounding circumstances, objectively viewed, show that the primary
purpose of the exchange at issue was to provide medical care or to gather evidence.”); Thompson
v. State, 2019 OK Cr 3, ¶12, 438 P.3d 373, 377 (collecting cases), cert. denied, 140 S. Ct. 171(2019).
10
WASH. STATE DEP’T OF COMMERCE, SEXUAL ASSAULT RESPONSE: INCREASING SEXUAL
ASSAULT NURSE EXAMINER AVAILABILITY AND ACCESS STATEWIDE 14 (2019) (hereinafter
SEXUAL ASSAULT RESPONSE) [https://perma.cc./BWR6-V5KX]; see also Linda A. Hutson,
Development of Sexual Assault Nurse Examiner Programs, 37 NURSING CLINICS OF N. AM. 79, 79
(2002) (“A sexual assault nurse examiner (SANE) is a registered nurse (RN) specially trained in
the comprehensive care of the survivor of sexual assault.”). Linda E. Ledray & Sherry Arndt,
Examining the Sexual Assault Victim: A New Model for Nursing Care, 32 J. PSYCHOSOCIAL
NURSING & MENTAL HEALTH SERVS. 7, 11-12 (1994) (“The role of the nurse examiner goes far
beyond collecting forensic evidence that will be useful should the case go to court. Her role
involves providing comprehensive care for the survivor and working cooperatively with other
individuals in the legal system. The forensic nurse working in this role is uniquely qualified to
provide the comprehensive care necessary to the sexual assault survivor. Treating injuries,
preventing pregnancy from occurring or proceeding, and preventing the contraction of a sexually
transmitted disease from the rape helps reduce secondary injury. Crisis intervention and supportive
counseling help the victim move toward recovery and survivor status.”).
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EXAMINER (SANE) DEVELOPMENT & OPERATION GUIDE 5 (1999)
[https://perma.cc/75M7-6SNC]. Patients who were victims of sexual assault often
had to wait for hours in busy, public areas because their injuries were viewed as less
serious than those of other trauma patients. Id. Medical providers were not
sufficiently trained to perform “medical-legal” exams or provide expert witness
testimony. Id. Additionally, these patients were often retraumatized by the process
of the exam and by the way they were treated by the medical providers. Id. (“Even
when the victim’s medical needs were met, their emotional needs all too often were
overlooked, or even worse, the victim was blamed for the rape by the [emergency
department] staff.” (citations omitted)); Linda A. Hutson, Development of Sexual
Assault Nurse Examiner Programs, 37 NURSING CLINICS OF N. AM. 79, 79 (2002).
Today, sexual assault nurse examiners “receive specialized training in
forensic evidence collection, sexual assault trauma response, forensic techniques
using special equipment, expert-witness testimony, assessment and documentation
of injuries, identifying patterned injury, and maintenance of chain of evidence.”
Debra Patterson, Rebecca Campbell & Stephanie M. Townsend, Sexual Assault
Nurse Examiner (SANE) Program Goals and Patient Care Practices, 38 J. NURSING
SCHOLARSHIP 180, 181 (2006) (hereinafter SANE Program Goals). They are
responsible for conducting sexual assault exams, “including crisis intervention, STD
prevention, pregnancy risk evaluation and interception, collection of forensic
20
State v. Burke
No. 96783-1
evidence, and referrals for additional support and care.” LEDRAY, supra, at 11.
Though documenting and collecting evidence are some of the critical responsibilities
of a sexual assault nurse examiner, so is providing medical care. 11 Sexual assault
nurse examiners provide medical care specific to sexual assault regardless of
whether or not the patient wishes to report the crime to police. Id. at 11-12; SEXUAL
ASSAULT RESPONSE, supra, at 16-17.
In this case, Nurse Frey testified that her duties as a sexual assault nurse
examiner were twofold: both to collect evidence and to provide medical care. At the
hearing, Nurse Frey testified about her background in medicine as well as her duties
as a sexual assault nurse examiner. She described those duties as providing forensic
evaluations and medical care for patients who presented with a history of sexual
assault. She explained that, according to her medical training, taking the patient’s
history is the “most important thing” for treating patients—including “sexual assault
patients”—because it guides the medical provider in determining where to look for
injuries and what medication is appropriate. 6 VTP (Nov. 3, 2016) at 545-46. Nurse
Frey followed protocols to collect and preserve physical samples, but she did not
take any direction from law enforcement regarding the steps she should take in the
11
SEXUAL ASSAULT RESPONSE, supra, at 9 (“Sexual assault response is an issue of both
public health and criminal justice: It is important that patients receive adequate treatment for their
physical and mental injuries, victims receive justice and perpetrators are prosecuted for their
crimes.” (emphasis omitted)); see also SANE Program Goals at 181-82 (“‘providing high quality
medical care’ was rated as a primary program goal” by 90 percent of participating programs).
21
State v. Burke
No. 96783-1
exam, and no member of law enforcement was present during the exam. Cf. Beadle,
173 Wn.2d at 109 & n.10 (CPS worker was present during police interrogation “only
to assist the police department—not to protect [the child’s] welfare in her capacity
as a CPS employee” (emphasis added)). Finally, although the exam itself was paid
for by state and federal crime victims’ compensation funds, 12 Nurse Frey was
employed and paid by a health care organization; she was not paid with
governmental funds. Thus, Nurse Frey’s forensic duties did not subordinate her
medical responsibilities but, rather, supplemented them.
Under these circumstances, we decline to hold that a sexual assault nurse
examiner acts as an agent of police. Instead, we view Nurse Frey as a medical
provider, to whom statements “are ‘significantly less likely to be testimonial than
12
See RCW 7.68.170 (prohibiting hospitals for billing or charging costs of sexual assault
exams to the victim of the assault when the examination is performed for the purposes of gathering
evidence of possible prosecution); WAC 296-30-170 (costs must be billed to the crime victims
compensation program). The medical forensic evaluation is also used as evidence to verify that the
medical care was provided to treat an injury resulting from a criminal act, which is necessary to
determine whether medical care can be paid for by the crime victims compensation program. WAC
296-30-010. The concurrence and amicus curiae suggest that because the exam had to be billed to
the crime victims compensation program, Nurse Frey must have represented that gathering
evidence was the sole purpose of the exam. As discussed above, it is not clear that the forensic
component overrides the medical treatment component of a sexual assault forensic exam (either in
general or in this specific case). Moreover, whether RCW 7.68.170 and WAC 296-30-170 limit
billing the State for sexual assault exams to only those exams whose primary or sole purpose is to
gather evidence for prosecution is not a question squarely before us. In any event, we do not think
that the intricacies of medical billing systems can be determinative of whether statements a sexual
assault patient makes to a medical professional specializing in sexual assault exams are testimonial
for purposes of the confrontation clause of the Sixth Amendment. While relevant to the inquiry,
the funding structure of the exam does not determine the primary purpose of the statements made
in the course of the exam.
22
State v. Burke
No. 96783-1
statements given to law enforcement officers’ because medical personnel are ‘not
principally charged with uncovering and prosecuting criminal behavior.’” Scanlan,
193 Wn.2d at 767 (emphasis added) (quoting Clark, 576 U.S. at 249).
Burke argues that K.E.H.’s statements should be viewed as testimonial
because Nurse Frey was not gathering information in response to an ongoing
emergency. However, our inquiry does not turn on the existence of an ongoing
emergency for two reasons. First, since Nurse Frey was not acting as law
enforcement, the primary purpose of the statements is not limited to either creating
testimony or addressing an ongoing emergency. “[T]he existence of an ‘ongoing
emergency’ at the time of an encounter between an individual and the police is
among the most important circumstances informing the ‘primary purpose’ of an
interrogation.” Bryant, 562 U.S. at 361 (emphasis added). The existence of an
ongoing emergency is often an indicator that a statement to law enforcement (or its
agents) is nontestimonial. See, e.g., id. at 374-78 (police responding to radio
dispatch); Davis, 547 U.S. at 827 (911 operator). But see Clark, 576 U.S. at 246
(preschool teachers). Statements made to police are often made under circumstances
that would lead an objective declarant to believe that they would be used to prove
past facts at trial, or else under circumstances evincing an ongoing emergency that
police are necessary to resolve. See, e.g., Crawford, 541 U.S. at 52; Bryant, 562 U.S.
23State v. Burke
No. 96783-1
at 375-76. However, when declarants speak to someone other than law enforcement,
there may be a multitude of purposes for the statements.
Second, “the existence vel non of an ongoing emergency is not the touchstone
of the testimonial inquiry,” and “there may be other circumstances, aside from
ongoing emergencies, when a statement is not procured with a primary purpose of
creating an out-of-court substitute for trial testimony.” Bryant, 562 U.S. at 374, 358.
For example, in Scanlan, we held that none of a domestic violence victim’s
statements to his medical providers were testimonial: some were made to determine
whether there was an ongoing emergency, while others were made for medical
purposes. 193 Wn.2d at 768-69. The patient’s statements identifying his assailant
“were elicited by ‘questions . . . meant to identify the abuser in order to protect the
victim from future attacks.’” Id. (alteration in original) (quoting Clark, 576 U.S. at
247). The medical providers needed to know the identity of the assailant to determine
whether the patient would be safe upon discharge or whether he needed referrals for
social services. Id. at 759-60. This was true in the contexts of both emergency and
follow-up treatment. Id. Moreover, the “statements to medical providers describing
the cause of his injuries were elicited for the purpose of obtaining medical
treatment.” Id. at 768. Several of the medical providers testified that they needed to
know how the patient’s injuries occurred in order to determine how serious the
injuries were, whether they were related to underlying medical conditions, and
24
State v. Burke
No. 96783-1
whether the medical providers needed to take measures to prevent new or recurring
injuries. Id. at 759-60. Scanlan makes clear that obtaining medical treatment is a
nontestimonial primary purpose, distinct from an ongoing emergency.
The circumstances and K.E.H.’s statements indicate that nearly all of the
statements were made primarily for medical purposes. K.E.H. made these statements
in a medical exam room in a hospital. She needed medical treatment specific to her
sexual assault, which Nurse Frey provided. Although K.E.H. had been medically
cleared from the emergency department, this did not mean that she was no longer in
need of any medical treatment. Instead, she was no longer in need of emergency
medical treatment and was cleared to go on to the next step for her: the sexual assault
exam. While some patients in this situation may choose to leave the hospital and not
attend this exam, it is uncontroverted that this is part of the process of treating a
sexual assault patient. This was this patient’s next step, and the fact that the hospital
did not have the staff to address this step immediately does not mean the statement
was nonmedical in purpose. Additionally, while the consent form K.E.H. signed
indicated that general medical care would not be provided during the sexual assault
exam, Nurse Frey did provide treatment and prescribe medication specific to the
sexual assault during her exam. In fact, Nurse Frey discovered the cervical laceration
that the emergency physician had not discovered during K.E.H.’s general medical
treatment earlier in the day.
25
State v. Burke
No. 96783-1
Most of K.E.H.’s statements had either two purposes (medical and forensic)
or an exclusive medical purpose. For example, questions about contraception and
ejaculation indicated whether and where DNA evidence might be collected, but they
were also necessary to determine whether the patient needed medication to treat
sexually transmitted infections or prevent pregnancy. Additionally, while the
possibility of strangulation and the patient’s position during the assault indicated the
degree of force (which would bear on what crime the perpetrator could be charged
with), that information also revealed where the patient had additional injuries that
needed treatment. K.E.H. also talked about missing crutches that she needed to walk
(due to arthritis, not due to an injury incurred during the assault) and answered
questions about allergies to medications—matters that were certainly relevant to
medical treatment but unrelated to the sexual assault. K.E.H.’s account of the assault
was part of the patient history, and Nurse Frey testified that she always started with
an open-ended question about what happened because patient history is “the most
important thing,” according to her medical training. 6 VTP (Nov. 3, 2016) at 545.
Further, the consent form K.E.H. signed at the beginning of the exam
indicated that medical records of the exam, including “photographs, lab results, [and]
written documentation” would be kept confidential. Pretrial Mot. Ex. 19B (emphasis
omitted). K.E.H.’s statements were contained in the written documentation, which
would remain confidential; they were not part of the physical evidence, which would
26
State v. Burke
No. 96783-1
be released to police. The patient history that Nurse Frey described as the most
important aspect of medical treatment was among the written records that would
remain confidential. Regardless of the forensic purposes for taking swabs and
collecting clothing, the primary purpose of eliciting nearly all of the statements
K.E.H. made during the course of the exam was to guide the medical exam; the
statements were used to create the documentation, which would become part of the
highly confidential medical records.
Together, K.E.H.’s and Nurse Frey’s statements and actions in the context of
a sexual assault exam indicate that the primary purpose of nearly all of K.E.H.’s
statements was not to provide an out-of-court substitute for trial testimony but to
guide medical treatment for sexual assault. Statements patients make to medical
providers “are ‘significantly less likely to be testimonial than statements given to
law enforcement officers’ because medical personnel are ‘not principally charged
with uncovering and prosecuting criminal behavior.’” Scanlan, 193 Wn.2d at 767
(quoting Clark, 576 U.S. at 249). It is not the nurse’s principal duty to uncover and
prosecute criminal behavior, even when they are tasked with collecting evidence as
part of their specialized training. The statements were made in a hospital exam room,
not a police station. No member of law enforcement was present during the exam,
and Nurse Frey did not take any direction from law enforcement. Additionally,
Nurse Frey provided medical care specific to sexual assault. Finally, these
27
State v. Burke
No. 96783-1
statements were elicited for both medical and forensic purposes, if not exclusively
medical purposes. Nearly every statement K.E.H. made during the exam was
necessary to guide the medical component in the exam, and their primary purpose
was not to create an out-of-court substitute for trial testimony. Under these
circumstances, most of K.E.H.’s statements cannot be characterized as primarily
testimonial. With the exception of one statement describing the assailant (discussed
below), we hold that the primary purpose of K.E.H.’s statements during the sexual
assault exam was to receive medical care. Thus, the statements were nontestimonial
and their admission did not violate the confrontation clause.
2. Testimonial Statement
“[A] conversation could contain both testimonial and nontestimonial
statements.” Koslowski, 166 Wn.2d at 419 (citing Davis, 547 U.S. at 828). “[T]rial
courts will recognize the point at which, for Sixth Amendment purposes, statements
. . . become testimonial. Through in limine procedure, they should redact or exclude
the portions of any statement that have become testimonial, as they do, for example,
with unduly prejudicial portions of otherwise admissible evidence.” Davis, 547 U.S.
at 829. In this case, K.E.H. made both testimonial and nontestimonial statements
during the course of the sexual assault exam. Most of K.E.H.’s statements did not
implicate the confrontation clause, but the trial court erred in admitting the one that
did.
28
State v. Burke
No. 96783-1
One statement was testimonial. One of the questions Nurse Frey asked when
taking K.E.H.’s patient history sought a “description of assailant(s).” Pretrial Mot.
Ex. 19C. Nurse Frey read K.E.H.’s answer to the jury, which described the
assailant’s appearance and clothing. Although this question could conceivably elicit
answers designed to address patient safety, rather than information that would assist
police in investigating or prosecuting a crime, 13 that was not the case here. K.E.H.
gave no indication that she knew the attacker. Her answer to that question did not
provide guidance for medical treatment, other than to rule out a potential concern
for her safety. K.E.H.’s description of the assailant more closely resembles a
statement one might make in a police interrogation (to assist law enforcement in
identifying and apprehending a suspect) or at trial (to identify the defendant as the
assailant). K.E.H. described the assailant’s height, skin color, and clothing—facts
that had no bearing on her injuries but would be highly relevant to identifying the
person responsible for the rape for further prosecution.
13
For example, Nurse Frey testified that as a sexual assault nurse examiner, she sometimes
saw victims of domestic violence, for whom she would also provide medical care and forensic
evaluations. If a patient described the assailant as an acquaintance or romantic partner, the medical
provider would be on alert about a potential continued danger to the patient and might help the
patient arrange for a safe place to go after discharge. See Clark, 576 U.S. at 246-47; Scanlan, 193
Wn.2d at 768-69. When a sexual assault patient describes the assailant as an intimate partner, the
statement’s primary purpose might be to guide the provision of medical care or to address an
ongoing emergency regarding the patient’s safety upon discharge. See, e.g., Scanlan, 193 Wn.2d
at 768-69; see also Bryant, 562 U.S. at 368 (“Victims are also likely to have mixed motives when
they make statements to police. During an ongoing emergency, a victim is most likely to want the
threat to her and to other potential victims to end, but that does not necessarily mean that the victim
wants or envisions prosecution of the assailant. A victim may want the attacker to be incapacitated
temporarily or rehabilitated.”).
29
State v. Burke
No. 96783-1
K.E.H.’s statement describing the assailant was testimonial. Its primary
purpose was not to guide the medical exam but to identify the person who could be
prosecuted for the sexual assault. The trial court erred in admitting this statement.
However, as discussed below, that error was harmless.
B. Harmless Error
The admission of K.E.H.’s description of the assailant was erroneous but
harmless. Under the constitutional harmless error standard, the State has the burden
of establishing harmless error beyond a reasonable doubt. State v. Guloy, 104 Wn.2d
412, 425, 705 P.2d 1182 (1985). The error is harmless “[i]f the untainted evidence
is so overwhelming that it necessarily leads to a finding of the defendant’s guilt.”
Koslowski, 166 Wn.2d at 431.
K.E.H.’s description of the assailant was relevant only to identifying Burke as
the person who raped her, but it was cumulative evidence of Burke’s identity. Officer
Phan testified that K.E.H. had given him a description of the assailant early in the
morning on July 3, 2009, shortly after the assault. He went straight to the park to
investigate the scene and look for witnesses or someone matching her description,
but he found no one.
Burke was identified as a suspect years later, when the crime lab identified a
match between his DNA and the sample collected from K.E.H.’s underwear. The
forensic DNA analyst testified extensively about the process of testing and matching
30
State v. Burke
No. 96783-1
DNA. She testified that the chances of someone other than Burke contributing the
male DNA found on K.E.H.’s underwear was 1 in 170 quadrillion. Even without
K.E.H.’s testimonial description of the assailant, the untainted DNA evidence
identifying Burke as the person who sexually assaulted her was overwhelming.
Although K.E.H.’s description of the assailant was testimonial, it was
harmless error to admit it.
C. Statements Made for the Purpose of Medical Diagnosis or Treatment
Burke also argues that K.E.H.’s statements to the sexual assault nurse
examiner should not have been admitted because they were hearsay and did not fall
under the exception for statements made for the purpose of medical diagnosis or
treatment. When a statement is nontestimonial, “the admissibility of a statement is
the concern of state and federal rules of evidence, not the Confrontation Clause.”
Bryant, 562 U.S. at 359; see also, e.g., Crawford, 541 U.S. at 40 (noting that the
State had invoked ER 804(b)(3) for statements against interest); State v. Ohlson, 162
Wn.2d 1, 9-10, 168 P.3d 1273 (2007) (excited utterances). In order for K.E.H.’s
statements to be admissible, they must be nontestimonial and comply with the rules
of evidence.
An out-of-court statement used to prove the truth of the matter asserted is
inadmissible hearsay under the rules of evidence unless an exception applies. ER
801(c), 802. Statements made for the purposes of medical diagnosis or treatment are
31
State v. Burke
No. 96783-1
an exception to the bar on hearsay. ER 803(a)(4) (allowing statements “describing
medical history, or 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 or treatment”).
Unlike the objective primary purpose test for the confrontation clause, the test
for statements made for medical diagnosis or treatments considers the subjective
purposes of both the declarant and the medical professional. Compare Bryant, 562
U.S. at 360, with State v. Doerflinger, 170 Wn. App. 650, 664, 285 P.3d 217 (2012).
For the statement to be “reasonably pertinent” to medical diagnosis or treatment
under ER 803(a)(4), the declarant’s motive in making the statement must be to
promote treatment and the medical professional must have relied on it for the
purposes of treatment. Doerflinger, 170 Wn. App. at 664. Statements attributing
fault are generally inadmissible under this exception, but statements “disclosing the
identity of a closely-related perpetrator” may be reasonably pertinent to treatment in
certain situations like domestic violence or sexual abuse “because part of reasonable
treatment and therapy is to prevent recurrence and future injury.” State v. Williams,
137 Wn. App. 736, 746, 154 P.3d 322 (2007).
We review evidentiary rulings for abuse of discretion. Ohlson, 162 Wn.2d at
7-8. “We will not reverse the trial court’s decision ‘unless we believe that no
32
State v. Burke
No. 96783-1
reasonable judge would have made the same ruling.’” Id. at 8 (quoting State v.
Woods, 143 Wn.2d 561, 595-96, 23 P.3d 1046 (2001)).
The trial court did not abuse its discretion in admitting most of K.E.H.’s
statements as reasonably pertinent to medical diagnosis or treatment. It is reasonable
to believe that K.E.H.’s motive was to promote treatment and that Nurse Frey relied
on the statements for the purposes of treatment. K.E.H.’s statements about her pain
level, allergies to medication, and need for her crutches had no other purpose than
to receive medical treatment. Her answers to the questions about penetration,
ejaculation, contraception, strangulation, grabbing, and her position during the
assault were also likely motivated by a desire to promote medical treatment specific
to sexual assault. Nurse Frey reviewed the consent agreement with K.E.H. at the
beginning of the exam, which explained the dual purposes of the exam and provided
that written documentation would remain confidential. K.E.H.’s description of the
assault was an answer to the first question Nurse Frey asked when they began the
sexual assault exam. Medical professionals often ask patients how their injuries are
caused, see Scanlan, 193 Wn.2d at 768, and it is reasonable to believe that K.E.H.
understood the question “Can you tell me what happened in Wright Park?” to be the
starting point for a medical exam. Pretrial Mot. Ex. 19E. Similarly, K.E.H.’s
description of the location of the assault was necessary to explain how she arrived at
the hospital in the middle of the night after the assault without her crutches: she was
33
State v. Burke
No. 96783-1
unhoused and had been residing in Wright Park, only one block away from Tacoma
General.
Additionally, Nurse Frey relied on K.E.H.’s answers for the purposes of
medical treatment. As she testified, the specific questions she asked K.E.H. guided
the exam. Based on K.E.H.’s answers to these questions, Nurse Frey did not
prescribe medication K.E.H. was allergic to and she examined K.E.H. consistent
with the specific sexual assault acts K.E.H. reported.
A reasonable judge could have concluded that K.E.H.’s motive in making
these statements was to promote medical treatment and that Nurse Frey relied on the
statements to provide medical treatment. The trial court did not abuse its discretion
in admitting these statements as statements made for the purpose of medical
diagnosis or treatment.
The court did abuse its discretion in admitting K.E.H.’s description of the
assailant under this exception. There is no evidence to suggest that K.E.H.’s
description of her assailant was made to promote medical treatment. Although Nurse
Frey sometimes treated victims of domestic violence and could have relied on
K.E.H.’s description to rule out the continued danger of intimate partner violence,
K.E.H. did not seem to know the assailant. 14 In cases where statements attributing
14
See State v. Price, 126 Wn. App. 617, 640, 109 P.3d 27 (2005) (holding that statements
a woman made to a doctor, identifying her boyfriend as the person who strangled her, were
admissible under ER 804(a)(4) because “a statement attributing fault to an abuser can be
34
State v. Burke
No. 96783-1
fault have been admitted under this exception, the declarant disclosed “the identity
of a closely-related perpetrator” who might cause future injury. Williams, 137 Wn.
App. at 746 (citing State v. Ackerman, 90 Wn. App. 477, 482, 953 P.2d 816 (1998);
State v. Sims, 77 Wn. App. 236, 239, 890 P.2d 521 (1995)). Here, there is no
evidence that K.E.H. was motivated to identify a closely related perpetrator who
might pose a continued danger to her; her description of the assailant is more like a
general attribution of fault, which is not reasonably pertinent to medical diagnosis
or treatment. The court abused its discretion in admitting this statement under ER
803(a)(4). However, as explained above, this error was harmless because Burke’s
identity was established through DNA evidence.
D. Legal Financial Obligations
Finally, Burke seeks to have several legal financial obligations stricken from
his sentence, in light of 2018 amendments to the statutes governing legal financial
obligations and this court’s decision in State v. Ramirez, 191 Wn.2d 732, 426 P.3d
714 (2018). Engrossed Second Substitute House Bill 1783, 65th Leg., Reg. Sess.
reasonably pertinent to treatment in domestic assault cases. A physician’s treatment will
necessarily differ when the abuser is a member of the victim’s family or household; for example,
the treating physician may recommend special therapy or counseling and instruct the victim to
remove himself or herself from the dangerous environment by leaving the home and seeking
shelter elsewhere” (citation omitted) (citing State v. Sims, 77 Wn. App. 236, 239, 890 P.2d 521(1995))), abrogated on other grounds by State v. Hampton, 184 Wn.2d 656, 665, 361 P.3d 734(2015). For similar reasons as discussed under our confrontation clause analysis, see supra note
13, the relationship between the declarant and the assailant may affect the applicability of this
hearsay exception.
35
State v. Burke
No. 96783-1
(2018) (House Bill 1783) “eliminates interest accrual on the nonrestitution portions
of LFOs, it establishes that the DNA database fee is no longer mandatory if the
offender’s DNA has been collected because of a prior conviction, and it . . . prohibits
imposing the $200 filing fee on indigent defendants.” Ramirez, 191 Wn.2d at 747
(citing LAWS OF 2018, ch. 269, §§ 1, 18, 17). House Bill 1783 became effective on
June 7, 2018, and it applies to legal financial obligations imposed on criminal
defendants whose cases were not yet final when these amendments were enacted. Id.
Burke’s judgment and sentence ordered him to pay a $200 criminal filing fee and a
$100 fee for the collection of DNA, plus interest on these legal financial obligations.
However, the trial court found Burke to be indigent, and his DNA had, in fact,
previously been collected. Thus, the filing fee, the DNA fee, and the interest
provision are no longer authorized for this case, which was still pending when House
Bill 1783 was enacted. Accordingly, we remand to the trial court to amend the
judgment and sentence to strike the requirements to pay the $200 criminal filing fee
and the $100 DNA collection fee, and to amend the interest provisions to reflect that
interest will not accrue on nonrestitution legal financial obligations after June 7,
2018.
III. CONCLUSION
The confrontation clause of the Sixth Amendment protects the right of the
accused to be confronted with witnesses against them, but only out-of-court
36
State v. Burke
No. 96783-1
statements that are testimonial implicate this right. Under the circumstances of this
sexual assault exam, nearly all of K.E.H.’s statements to the sexual assault nurse
examiner were nontestimonial; those statements do not implicate the confrontation
clause. Only her description of the assailant was testimonial, but the error in
admitting that statement was harmless. Further, the trial court did not abuse its
discretion in admitting the majority of the statements as statements made for the
purpose of medical diagnosis or treatment, and the error in admitting K.E.H.’s
description of the assailant under that hearsay exception was likewise harmless. We
reverse the Court of Appeals and remand to the trial court for further proceedings in
accordance with this opinion.
37
State v. Burke
No. 96783-1
______________________________
Montoya-Lewis, J.
WE CONCUR:
___________________________ ______________________________
___________________________ ______________________________
___________________________ ______________________________
___________________________ ______________________________
38
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
No. 96783-1
GORDON McCLOUD, J. (concurring)—Nurses are health care
professionals. Nurses “promot[e] and maintain[] health.”1 Sexual assault nurse
examiners (SANEs) discharge such nursing duties.
But SANEs also perform forensic duties. “Forensic” means “pertaining to,
connected with, or used in courts of law . . . .” 2 In this case, that “connect[ion] with
. . . courts of law” was clear from the evidence: the SANE conducted an exam that
was funded (pursuant to ch. 7.68 RCW) by a state victims compensation fund,
sought evidence that could support a criminal prosecution, and had a patient who
stayed for the exam for the specific purpose of providing such forensic evidence to
aid law enforcement. As a result, the patient—K.E.H.—believed, quite rightly,
1
MERRIAM-WEBSTER ONLINE DICTIONARY, https://www.merriam-
webster.com/dictionary/nurse (last visited Jan. 8, 2021); see also What Is Nursing?, AM.
NURSES ASS’N, https://www.nursingworld.org/practice-policy/workforce/what-is-
nursing/ (last visited Jan. 8, 2021).
2
DICTIONARY.COM, https://www.dictionary.com/browse/forensic# (last visited
Jan. 8, 2021); see also MERRIAM-WEBSTER ONLINE DICTIONARY, https://www.merriam-
webster.com/dictionary/forensic (“forensic” means “belonging to, used in, or suitable to
courts of judicature”) (last visited Jan. 8, 2021).
1
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
that her medical care was basically over after her initial emergency room (ER)
evaluation and treatment. She stayed to see the SANE for forensic purposes: to
help make sure the attacker was not “out there doing this to someone else.” 6
Verbatim Transcript of Proceedings (VTP) (Nov. 3, 2016) at 622.
The fact that that forensic exam was conducted by a trained, professional,
compassionate member of the medical profession, rather than by a law
enforcement officer, is a significant advance for patient care—an advance that is
particularly important for those rape victims who lack the ability to advocate
strongly for themselves. But we are not presented with a medical care question;
we are presented with a legal question. The legal question that the confrontation
clause3 compels us to ask is whether the statements elicited by the SANE, to help
prevent the person who raped K.E.H. from “doing this to someone else,” are
testimonial—i.e., made primarily to help law enforcement and prosecution—or
nontestimonial —i.e., made primarily for medical treatment.
The majority answers this question by focusing on each separate statement
K.E.H. made and looking at the character of that statement. I respectfully disagree
with this approach. I think that controlling decisions of the United States Supreme
Court compel us to look at the overall purpose of the discussion/interrogation first
3
U.S. CONST. amend. VI.
2
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
and consider each statement in that context. And in this case, that contextual
analysis shows that K.E.H.’s statements to the SANE were made in anticipation of
prosecuting the rapist; hence, they were testimonial for Sixth Amendment
purposes. I concur, however, because the admission of the testimonial statements
was harmless beyond a reasonable doubt.
I. K.E.H.’s Statements to SANE Kay Frey during the Forensic Examination
Were Testimonial
A. To Determine Whether K.E.H.’s Statements to the SANE Were
Testimonial, We Focus on the Context of the Entire Forensic Exam
The confrontation clause of the Sixth Amendment guarantees that “[i]n all
criminal prosecutions, the accused shall enjoy the right . . . to be confronted with
the witnesses against him.” U.S. CONST. amend. VI. “Witnesses” are those who
“‘bear testimony.’” Crawford v. Washington, 541 U.S. 36, 51, 124 S. Ct. 1354, 158
L. Ed. 2d 177 (2004) (quoting 2 NOAH WEBSTER, AN AMERICAN DICTIONARY OF
THE ENGLISH LANGUAGE (1828)). Thus, out-of-court testimonial statements are
inadmissible at trial against a criminal defendant if the declarant is “‘unavailable to
testify,’” unless “‘the defendant had had a prior opportunity for cross-
examination.’” Davis v. Washington, 547 U.S. 813, 821, 126 S. Ct. 2266, 165 L.
Ed. 2d 224 (2006) (quoting Crawford, 541 U.S. at 53-54). I agree with the
majority on all of these points.
3
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
The majority is also correct in holding that we use the primary purpose test
to determine whether such out-of-court statements are testimonial. Majority at 2
(citing Ohio v. Clark, 576 U.S. 237, 245, 135 S. Ct. 2173, 192 L. Ed. 2d 306(2015); State v. Scanlan, 193 Wn.2d 753, 766, 445 P.3d 960 (2019), cert. denied,
140 S. Ct. 834 (2020)).
But controlling United States Supreme Court precedent makes clear that the
primary purpose test focuses on the purpose “of the interrogation,” Davis, 547
U.S. at 822 (emphasis added)—not on a single question and answer within that
interrogation. The individual statements made during the course of an
interrogation are, of course, relevant to determining the primary purpose of that
interrogation. Courts must, however, focus on the overall context. Clark, 576 U.S.
at 249.
The Supreme Court clearly adopted this approach because of the concerns
that led to the adoption of the confrontation clause in the first place. In Crawford,
for example, the Court traced the history of the development of the confrontation
right at English common law and in early America and concluded that “the
principal evil at which the Confrontation Clause was directed was the civil-law
mode of criminal procedure, and particularly its use of ex parte examinations as
4
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
evidence against the accused”; it then directed that “[t]he Sixth Amendment must
be interpreted with this focus in mind.” Crawford, 541 U.S. at 50.
“This focus” is a focus on the overall procedure by which the state obtains
statements from its witnesses. With that focus, the Supreme Court has consistently
emphasized that trial courts must determine not whether the primary purpose of a
specific statement in isolation is testimonial but, rather, whether “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 (emphasis added); see also
Clark, 576 U.S. at 249 (“[c]ourts must evaluate challenged statements in context”
in conducting a primary purpose analysis); Michigan v. Bryant, 562 U.S. 344, 370,
131 S. Ct. 1143, 179 L. Ed. 2d 93 (2011) (courts “should determine the primary
purpose of the interrogation by objectively evaluating the statements and actions of
the parties to the encounter, in light of the circumstances in which the interrogation
occurs” (internal quotation marks omitted)).
The majority, however, focuses on each individual statement within the
interrogation. For example, the majority initially explains that “[t]o determine
whether a statement is testimonial, we must identify its primary purpose,” and then
concludes that “under these circumstances, the primary purpose of nearly all of
[K.E.H.’s] statements” was nontestimonial. Majority at 2 (emphasis added). It
5
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
continues, “[S]tatements are nontestimonial when they have another primary
purpose,” and “[u]nder these circumstances, most of K.E.H.’s statements cannot be
characterized as primarily testimonial.” Id. at 15, 27 (emphasis added).
To be sure, the majority also quotes Davis for the rule that statements “‘are
testimonial when the circumstances objectively indicate that . . . the primary
purpose of the interrogation is to establish or prove past events potentially relevant
to later criminal prosecution.’” Id. at 13 (alteration in original) (emphasis added)
(quoting Davis, 547 U.S. at 822); see also id. at 14. But the majority does not
distinguish between this contextual approach and its other, largely statement-by-
statement, approach.
These two different approaches, however, are not interchangeable.
Conflating them deemphasizes the importance of the structural context in which a
conversation takes place. Davis, 547 U.S. at 821; Crawford, 541 U.S. at 52(statements are testimonial where they “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” (emphasis added) (internal quotation marks
omitted)).
This is not the first time that the Supreme Court has held that a “context”
approach sheds more light on the character of a statement than a “statement-by-
6
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
statement” approach does. In Missouri v. Siebert, for example—a Fifth
Amendment (rather than a Sixth Amendment) case—the Court examined the
constitutionality of a police interrogation strategy that divided up the interrogation
of a criminal suspect into two parts. 542 U.S. 600, 616, 124 S. Ct. 2601, 159 L. Ed.
2d 643 (2004); U.S. CONST. amend. V. In part one, officers would withhold
Miranda 4 warnings and question the suspect up to the point of a confession; in part
two, officers would give the already-confessing suspect Miranda warnings and
elicit a repetition of the confession. Id. at 616-17. The Court held that such a two-
part interrogation strategy made the belated Miranda warnings ineffective. Id.Hence, the Court concluded, the defendant’s confession repeated after the belated
warnings must be suppressed. Id. at 617. This was a commonsense approach that
appreciated procedural context in determining the character of a declarant’s
statements within that context.
The Sixth Amendment confrontation clause also provides a procedural
protection. Thus, it is not surprising that the Supreme Court has also emphasized
the importance of the procedural context to determining the character of a
declarant’s statements for Sixth Amendment purposes. In particular, the Supreme
Court requires us to maintain an overall focus on the identity of the interrogator,
4
Miranda v. Arizona, 384 U.S. 436, 86 S. Ct. 1602, 16 L. Ed. 2d 694 (1966).
7
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
their links to law enforcement, and whether the conversation was the result of a
formal procedure. Clark, 576 U.S. at 249 (“Courts must evaluate challenged
statements in context, and part of that context is the questioner’s identity.” (citing
Bryant, 562 U.S. at 369)).
It is certainly true that a single conversation may contain some statements
that are made primarily to help prosecute a suspect and some statements that are
made primarily for medical treatment or other reasons. But courts can’t determine
the testimonial or nontestimonial character of each statement by zooming in on its
language. Instead, we view those statements in context—and ask whether in
context, the entire conversation has shifted from nontestimonial to testimonial or
back again. In Davis, for example, the Court reviewed a 911 call that began with
the 911 operator asking questions to determine the need for emergency assistance.
547 U.S. at 828. Such questions would not typically produce testimonial answers.
But the Court continued, explaining that the answers can “‘evolve into testimonial
statements’” once the original purpose of meeting the emergency is met. Id.(quoting Hammon v. Indiana, 829 N.E.2d 444, 457 (2005), rev’d by Davis, 547
U.S. 813); see also State v. Koslowski, 166 Wn.2d 409, 419, 209 P.3d 479 (2009)
(citing Davis, 547 U.S. at 828). The focus, however, remained on the purpose of
the questions and answers in the context of the full conversation.
8
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
B. In Focusing on the Context of the Entire Forensic Exam, We Evaluate
Four Main Factors—All Point toward K.E.H.’s Statements Being
Testimonial
To evaluate that context (and whether it changed from testimonial to
nontestimonial), we use the primary purpose test set forth by the Supreme Court
and adopted by this court. “Under the primary purpose test, courts objectively
evaluate the circumstances in which the encounter occurs, as well as the parties’
statements and actions.” Scanlan, 193 Wn.2d at 767 (emphasis added) (citing
Bryant, 562 U.S. at 359). “‘[T]he question is whether, in light of all the
circumstances, viewed objectively, the “primary purpose” of the conversation was
to “creat[e] an out-of-court substitute for trial testimony.”’” Id. (second alteration
in original) (emphasis added) (quoting Clark, 576 U.S. at 245 (quoting Bryant, 562
U.S. at 358)). Statements are testimonial only when “the primary purpose of the
interrogation is to establish or prove past events potentially relevant to later
criminal prosecution.” Id. at 763 (some emphasis omitted) (quoting Davis, 547
U.S. at 822).
Here, four main factors make clear that the objective primary purpose of the
examination was to establish or prove past events potentially relevant to later
criminal prosecution: (1) the objective manifestation of K.E.H.’s intent in
undergoing the exam, (2) the objective manifestation of Frey’s intent in conducting
9
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
the exam, in light of the history and purpose of SANE nursing and the Washington
statutory scheme, (3) the lack of ongoing emergency, evidenced by the bifurcated
nature of the exam, and (4) the exam’s formality.
1. K.E.H.’s Intent
The declarant’s purpose in engaging in a conversation is a critically
important factor to consider. Clark, 576 U.S. at 247-48 (one factor in determining
whether 3-year-old child’s statements to his teachers were testimonial was the
child’s ability to form the intent that his statements be used by police or
prosecutors or as a substitute for trial testimony); Davis, 547 U.S. at 827 (intent of
victim in making a 911 call was factor bearing on whether statements on the call
were testimonial).
In this case, as the majority explains, K.E.H. was medically cleared by the
emergency department around 11 AM on July 3. 6 VTP (Nov. 3, 2016) at 603. By
this time, her case had already been reported to Tacoma police and K.E.H. had
provided them with a statement. 8 VTP (Nov. 8, 2016) at 836-38, 841. K.E.H.
then chose to wait in the hospital for almost five hours to undergo a sexual assault
examination. That exam was conducted by SANE Frey at around 4 PM. 6 VTP
(Nov. 3, 2016) at 605.
10
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
K.E.H. made clear to Frey that her goal for the exam—the reason she waited
hours for it in the hospital—was to prevent her attacker from being “out there
doing this to someone else.” Id. at 622; Pretrial Mot. Ex. 19F. In fact, K.E.H. told
Frey that this reason was “basically why she came.” 6 VTP (Nov. 3, 2016) at 622.
K.E.H.’s goal was reflected in her actions leading up to the SANE exam.
K.E.H. signed a consent form specifying that she was consenting to “a forensic
evaluation to be performed by a Forensic Nurse Examiner to include
documentation of the assault, collection of evidence, nursing care and treatment
limited to MultiCare Health System’s Forensic Nurse Examiner nursing
protocols.” Pretrial Mot. Ex. 19B (emphasis added); 6 VTP (Nov. 3, 2016) at 606.
The form indicated that “[a] forensic evaluation does not include general medical
care.” Pretrial Mot. Ex. 19B (emphasis added); 6 VTP (Nov. 3, 2016) at 557. It
explained that “evidence such as swabs, blood, hair, nail samples may be
collected” and that “in assault cases that have been reported to law enforcement,
the forensic nurse examiner may speak to the investigating officer.” 6 VTP (Nov.
3, 2016) at 558; Pretrial Mot. Ex. 19B. It noted that the “detailed medical records
(photographs, lab results, written documentation)” would be kept confidential but
could be disclosed “as allowed by law.” Pretrial Mot. Ex. 19B (emphasis omitted).
11
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
A discharge form given to K.E.H. after the examination 5 similarly explained
that K.E.H. had just undergone a forensic evaluation for “collection of evidence for
investigative purposes.” 6 VTP (Nov. 3, 2016) at 561; Pretrial Mot. Ex. 19I. It
further stated, “If your assault was reported to the police, your evidence will be
transferred directly to Tacoma Police Department.” 6 VTP (Nov. 3, 2016) at 561;
Pretrial Mot. Ex. 19I.
Viewed objectively, K.E.H.’s statement to Frey, coupled with her
knowledge of the forensic purpose of the examination as described on the consent
and discharge forms, indicates that her primary purpose in engaging in the
examination was not to seek medical treatment but to assist in evidence collection
that could be used to ensure her attacker did not “do[] this to someone else.” 6 VTP
(Nov. 3, 2016) at 622; Pretrial Mot. Ex. 19F.
2. SANE Frey’s Intent
The intent of Frey, viewed objectively, is also an important factor to
consider in determining whether K.E.H.’s out-of-court statements are testimonial.
5
Frey testified that she had not been able to retain a copy of the discharge form
signed by K.E.H. because K.E.H. “took both copies, originally,” and Frey had to fill out
another copy for her own records. 6 VTP (Nov. 3, 2016) at 561. Because of this, Frey
could not confirm that K.E.H. had signed the discharge form, but Frey testified that she
had given the form to K.E.H. and that it was common practice for the patient to sign the
discharge form because “there’s a place for the patient to sign it.” Id. at 562.
12
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
“Courts must evaluate challenged statements in context, and part of that context is
the questioner’s identity.” Clark, 576 U.S. at 249 (citing Bryant, 562 U.S. at 369).
Statements made to a questioner who “is not principally charged with uncovering
and prosecuting criminal behavior are significantly less likely to be testimonial
than statements given to law enforcement officers.” Id. However, the Court has
expressly declined to adopt a categorical rule excluding statements to nonpolice
questioners as beyond the reach of the confrontation clause. Id. at 246.
Here, Frey’s identity as a SANE colors the entire interaction and each
statement within it. An overview of the development of SANE nursing shows that
the primary purpose of a SANE’s interrogation in general is “to establish or prove
past events potentially relevant to later criminal prosecution.” Davis, 547 U.S. at
822.
The SANE specialization falls within the field of forensic nursing. What is
Forensic Nursing?, INT’L ASS’N OF FORENSIC NURSES,
https://www.forensicnurses.org/page/WhatisFN [https://perma.cc/D4H5-B3LV].
Thus, SANEs may also be referred to as forensic nurses or forensic nurse
examiners. 6 SANE programs were developed in response to “the inadequacy of the
6
Frey testified that her job title was “forensic nurse examiner.” 6 VTP (Nov. 3,
2016) at 554. Tacoma General Hospital also refers to its “Forensic Nurse Examiner
13
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
medical evidentiary examination.” Linda A. Hutson, Development of Sexual
Assault Nurse Examiner Programs, 37 NURSING CLINICS OF N. AM. 79, 84 (2002)
(hereinafter Development of SANE Programs). The first such programs were
developed in the 1970s, when “[m]any hospitals did not have a rape protocol” and
“[s]ome hospital personnel were afraid of the forensic component of evidence
collection.” Linda E. Ledray & Sherry Arndt, Examining the Sexual Assault
Victim: A New Model for Nursing Care, 32 J. PSYCHOSOCIAL NURSING & MENTAL
HEALTH SERVS. 7, 8 (1994) (hereinafter Examining the Sexual Assault Victim).
SANE programs thus were developed to address two main problems: that
untrained hospital staff retraumatized sexual assault victims when conducting
physical examinations, and that lack of training in the collection and preservation
of evidence specifically posed a problem for future prosecutions. Development of
SANE Programs at 84; see also Examining the Sexual Assault Victim at 8. Further,
“when evidence was collected by hospital staff, [that staff was] often unavailable
to law enforcement for the continuation of the investigation and prosecution of a
sexual assault case.” Development of SANE Programs at 79; see also Examining
the Sexual Assault Victim at 7.
service.” See Sexual Assault Services, MULTICARE, https://www.multicare.org/sexual-
assault-services/ [https://perma.cc/TNJ6-983M].
14
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
By contrast, SANEs are trained in “forensic evidence collection, sexual
assault trauma response, forensic techniques using special equipment, expert-
witness testimony, assessment and documentation of injuries, identifying patterned
injury, and maintenance chain of evidence.” Debra Patterson, Rebecca Campbell &
Stephanie M. Townsend, Sexual Assault Nurse Examiner (SANE) Program Goals
and Patient Care Practices, 38 J. NURSING SCHOLARSHIP 180, 181 (2006). While
providing compassionate medical care to sexual assault survivors has always been
an integral component of SANE nursing, “[t]he primary goal of the SANE is to
provide objective forensic evaluation of the survivors of sexual assault.”
Development of SANE Programs at 84.
SANE programs and nurses, then, frequently work closely with police and
prosecutors, even where they do not work directly for the police. Examining the
Sexual Assault Victim at 8. Here, Frey testified that she was employed by
MultiCare, the health care entity that operates Tacoma General Hospital. 6 VTP
(Nov. 3, 2016) at 548. Frey was not a law enforcement “official.” State v. Burke, 6
Wn. App. 2d 950, 969 n.4, 431 P.3d 1109 (2018). But the Supreme Court has made
clear that people conducting interrogations on behalf of the police may be
considered law enforcement agents for purposes of the confrontation clause
15
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
analysis.7 Indeed, some courts have recognized the close ties between SANEs and
law enforcement and have held that the primary purpose of SANE sexual assault
interviews is testimonial as a matter of law. 8
In addition, in this case, the cost of the SANE exam was covered by the
State pursuant to state statute. That statute, RCW 7.68.170, provides:
No costs incurred by a hospital or other emergency medical facility for the
examination of the victim of a sexual assault, when such examination is
performed for the purposes of gathering evidence for possible prosecution,
shall be billed or charged directly or indirectly to the victim of such assault.
Such costs shall be paid by the state pursuant to this chapter.
(Emphasis added.) The administrative code further explains that
7
See Davis, 547 U.S. at 823 n.2 (911 operators may be police agents when they
conduct interrogations of callers).
8
Hartsfield v. Commonwealth, 277 S.W.3d 239, 244 (Ky. 2009) (“We believe
their function of evidence gathering, combined with their close relationships with law
enforcement, renders SANE nurses’ interviews the functional equivalent of police
questioning.”); see also Medina v. State, 122 Nev. 346, 354-55, 143 P.3d 471 (2006)
(defining a SANE as a “police operative” because she “gathers evidence for the
prosecution for possible use in later prosecutions,” thus leading “an objective witness to
reasonably believe that the statements would be available for use at a later trial”). Courts
that have declined to adopt a per se rule regarding the primary purpose of SANE
examinations have still found that a SANE acted as a law enforcement agent when acting
in her evidence-collecting role. See, e.g., State v. Bennington, 293 Kan. 503, 523, 264
P.3d 440 (2011) (SANE asked victim questions from state-provided questionnaire as part
of completion of sexual assault evidence collection kit); State v. Miller, 293 Kan. 535,
578, 264 P.3d 461 (2011) (same); People v. Vargas, 178 Cal. App. 4th 647, 662, 100 Cal.
Rptr. 3d 578 (2009) (SANE who examined victim hours after assault did so “for the
primary purpose of documenting the nature of the sexual assault and gathering evidence
for transmittal to the police and for possible later use in court”).
16
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
[w]hen a sexual assault examination is performed for the purpose of
gathering evidence for possible prosecution, the costs of the examination
must be billed to the crime victims compensation program. We are the
primary payer of this benefit. The client is not required to file an application
with us to receive this benefit and may not be billed for these costs. If the
examination includes treatment costs or the client will require follow-up
treatment, an application for benefits must be filed with us for these services
to be considered for payment.
WAC 296-30-170 (emphasis added). Under Washington state law, the conclusion
seems inescapable that a SANE exam that is eligible for reimbursement by the
State is a SANE exam “performed for the purposes of gathering evidence for
possible prosecution.”
Consistent with the general statutory purpose of such SANE exams, the
consent form K.E.H. signed before the exam noted that “[a] forensic exam is
available to me at public expense, if eligible, according to RCW 7.68.170.” Pretrial
Mot. Ex. 19B. Frey confirmed that the exam was funded by the State. 6 VTP (Nov.
3, 2016) at 558. The hospital’s act of obtaining that funding from the State
indicates that a representation was made that the “examination [was] performed for
the purposes of gathering evidence for possible prosecution.” RCW 7.68.170.
Thus, while a SANE’s specialization may not “transform a class of medical
professionals into agents of the police,” majority at 19, the field of SANE nursing
17
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
has unique links to law enforcement, prosecution, and evidence collection that
distinguish it from other areas of medicine.
Indeed, the forensic purpose of SANEs distinguishes this case from Scanlan,
our recent confrontation clause case cited by the majority. 193 Wn.2d 753. In that
case, an elder abuse victim made statements to various medical providers
identifying the perpetrator and describing the cause of his injuries. Id. at 768. After
his ER visit, that victim signed release forms authorizing police and prosecutors to
obtain his medical records “in furtherance of the investigation and any resulting
prosecution.” Id. at 770, 775 (internal quotation marks omitted). We recognized
that obtaining medical treatment was a nontestimonial primary purpose,
acknowledging that “[a]s a threshold matter, [the victim’s] statements are
‘significantly less likely to be testimonial than statements given to law enforcement
officers’ because medical personnel are ‘not principally charged with uncovering
and prosecuting criminal behavior.’” Scanlan, 193 Wn.2d at 767 (quoting Clark,
576 U.S. at 249). And that was true of the medical providers in Scanlan, including
ER personnel, the victim’s primary care physician, and wound treatment
specialists, id. at 757; none of these fields of medical practice were developed with
a dual forensic and medical purpose, so the victim would have seen these same
18
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
professionals for emergency or follow-up care, regardless of whether he had signed
release forms or sought to press charges.
Frey, in contrast, did not provide general medical care—only medical care
“specific to . . . sexual assault.” 6 VTP (Nov. 3, 2016) at 565. In fact, she explained
that only the emergency department provided general medical care—“things like . .
. a full evaluation by the emergency room physician and any testing that might be
needed, that’s medical care done by the emergency department”—and that “[o]nce
[the victim is] cleared from that, then the forensic piece starts. So even though
medications are given by me at the end, based on protocols and such . . . the
overall medical responsibility is the emergency room provider.” Id. at 564
(emphasis added). K.E.H. was directed to follow up not with Frey but with Planned
Parenthood and to return to the ER if bleeding continued. Id. at 644; Pretrial Mot.
Ex. 19I.
To be sure, Frey’s exam had both medical and forensic purposes. 6 VTP
(Nov. 3, 2016) at 545. But consistent with her profession, she described an
overwhelmingly forensic purpose. Indeed, much of Frey’s testimony described the
forensic components of the exam, including photographing injuries and “doing any
DNA [deoxyribonucleic acid] retrieval that could be done.” Id. She described at
length the subsequent procedures she followed to package and preserve evidence,
19
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
including maintaining a chain of custody. Id. at 545, 550, 551, 559-60, 645-46.
And notably, she described “taking a [patient] history” as part of “the forensic
piece.” Id. at 545. She testified that the patient history helps the nurse know where
to look for evidence. Id. at 567.
The majority highlights the fact that Frey’s examination uncovered an
internal injury that had not previously been discovered by ER personnel. Majority
at 25-26; 6 VTP (Nov. 3, 2016) at 547. But it is not disputed that Frey’s duties
included medical treatment as well as forensic evidence collection, and Frey’s
discovery of this additional injury does not negate the fact that under these
circumstances, the primary purpose of this examination by a forensic nurse was to
collect evidence. The physical evidence collected was indisputably collected and
preserved for forensic purposes. 6 VTP (Nov. 3, 2016) at 559. The verbal
statements elicited from K.E.H. in order to facilitate the collection of that physical
evidence were equally testimonial—made with the primary purpose of “creating
evidence for [the defendant’s] prosecution.” Clark, 576 U.S. at 246 (explaining, by
contrast, that a conversation between a 3-year-old and his teachers who were
concerned about the possibility of child abuse at home did not have the primary
purpose of “creating evidence for . . . prosecution”). Thus, as a SANE charged with
collecting and preserving evidence in a form that could be used at a criminal trial,
20
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
Frey’s role was much closer to “uncovering and prosecuting criminal behavior,” id.
at 249, than were the roles of the medical personnel in Scanlan.
3. No Ongoing Emergency
The fact that there was no ongoing emergency at the time K.E.H. presented
to Frey is also a highly relevant factor “‘that informs the ultimate inquiry regarding
the “primary purpose” of an interrogation.’” Id. at 245 (quoting Bryant, 562 U.S.
at 366). For example, in Clark, the Court found it important that the teachers who
questioned the child regarding his bruises acted in response to an ongoing
emergency, namely whether it was safe to release the child into the custody of a
potentially abusive caregiver. Id. at 247. And in Scanlan, our court emphasized
that the statements to the medical personnel who treated the victim needed to be
analyzed in light of the fact that the providers were concerned with a similar
ongoing emergency—whether the victim would be safe upon returning home, since
his abuser was his live-in partner. 193 Wn.2d at 768-69.
Here, there was no such ongoing emergency. K.E.H.’s attacker was a
stranger, and thus, there was no similar concern that K.E.H. would be released
back into the control of an abusive partner or family member. K.E.H. had been
medically cleared by the emergency room and chose to wait for five hours to speak
with and be examined by the SANE. The bifurcated nature of the exam into an
21
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
emergency medical treatment component and a forensic examination component
further supports that the primary purpose of the interaction with the SANE was
testimonial. See, e.g., State v. Bennington, 293 Kan. 503, 518, 264 P.3d 440 (2011)
(statements made to SANE testimonial where victim was first questioned about
assault in presence of police officer and underwent examination afterward); State
v. Cannon, 254 S.W.3d 287, 305 (Tenn. 2008) (statements made to sexual assault
nurse were testimonial when emergency room medical professionals had examined
and treated the victim before she spoke to the nurse); State v. Hooper, 145 Idaho
139, 145-46, 176 P.3d 911 (2007) (statements made to forensic nurse at sexual
trauma center were testimonial when medical examination by physician had first
been conducted); United States v. Gardinier, 65 M.J. 60, 65-66 (2007) (statements
made to SANE were testimonial when made during a forensic medical examination
performed several days after the victim had been treated by other medical
professionals); United States v. Bordeaux, 400 F.3d 548, 556 (8th Cir. 2005)
(statements made to “forensic interviewer” were testimonial where a physician
separately provided victim with comprehensive medical care).
4. Formality of Examination
Finally, Crawford and its progeny make very clear that procedural formality
is an important factor in determining whether an interrogation has produced
22
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
testimonial statements. Crawford, 541 U.S. at 51; Davis, 547 U.S. at 827 (level of
formality of the conversation was important factor in determining that 911 call was
not testimonial); Bryant, 562 U.S. at 377 (“This situation is more similar, though
not identical, to the informal, harried 911 call in Davis than to the structured,
station-house interview in Crawford.”); Clark, 576 U.S. at 247 (“This was nothing
like the formalized station-house questioning in Crawford or the police
interrogation and battery affidavit in Hammon[9].”).
Frey emphasized that her examination was conducted according to a formal
forensic procedure, that is, MultiCare’s SANE protocol. 6 VTP (Nov. 3, 2016) at
545, 547, 550, 557, 564, 565, 645-46. In accordance with this protocol, Frey first
had K.E.H. sign the consent form and then proceeded to obtain a patient history.
Id. at 597. Frey asked an open-ended question to begin the patient history
documentation: “Can you tell me what happened in Wright[ ] Park?” Id. at 549,
611. This all followed that formal protocol. Id. at 545. Frey then completed
standard forms requiring her to ask a series of “more targeted questions” to K.E.H.
regarding the assault. 6 VTP (Nov. 3, 2016) at 613-17; Pretrial Mot. Exs. 19C,
19D. Frey next performed a head-to-toe physical exam, followed by a genital
9
Hammon v. Indiana, 547 U.S. 813, 126 S. Ct. 2266, 165 L. Ed. 2d 224 (2006),
was decided along with Davis.
23
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
exam. 6 VTP (Nov. 3, 2016) at 626, 631. She took swabs and collected evidence
according to protocol, eventually placing the completed rape kit into a refrigerator
to be picked up by police. Id. at 648-49. This structured, step-by-step procedure
much more closely resembles “formalized station-house questioning” by police
than it does an informal conversation between a preschool student and his teachers
or a frenzied 911 call made while the caller was still in immediate danger. Clark,
576 U.S. at 247; compare id. and Davis, 547 U.S. at 827, with Crawford, 541 U.S.
at 51; see also Dylan O. Keenan, Confronting Crawford v. Washington in the
Lower Courts, 122 YALE L.J. 782, 831 (2012) (“SANE nurses are trained to collect
evidence and assess sexual assault. Their structured questioning has much more in
common with the ex parte examinations that concerned the Framers than does the
conduct of a police officer who arrives along with the ambulance. Lower courts, by
excluding testimony from SANE nurses . . . are hewing closely to Crawford’s
contours.”).
In sum, the overall character of the SANE exam, following the ER exam,
was forensic: to develop evidence for potential use at trial. That character of the
exam remained the same from beginning to end. The compassion and skill with
which Frey treated the patient did not change that purpose. In fact, those qualities
made it easier for Frey to achieve that forensic purpose.
24
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
II. Admission of the Statements Was Harmless beyond a Reasonable Doubt
As a result, Frey elicited and then testified about numerous statements
K.E.H. made during the exam. Frey read the jury a statement K.E.H. made to her
that Frey had recorded on a form labeled “Forensic Evaluation: Patient Narrative”:
“I was sitting there rolling myself a cigarette. I know he covered my
mouth because I would have been screaming for help. I was taken to the
ground. I don’t know if he tried choking me or not. The next thing I knew, I
was taken to the ground, my pants were off and stuff, and he was inside me.
It was over and done with. I think he told me to keep my mouth shut. That’s
all I remember. Then I came here. I walked over to the hospital.”
6 VTP (Nov. 3, 2016) at 612; Pretrial Mot. Ex. 19E. Frey also read K.E.H.’s
description of her assailant into the record: “‘He was tall, a light black, no hair or
short hair. He had a white t-shirt and jeans. No jacket.’” 6 VTP (Nov. 3, 2016) at
614. Frey also testified as to K.E.H.’s answers to standardized questions included
on the “Forensic Evaluation: Patient History A” and “B” forms. Id. at 614-17;
Pretrial Mot. Exs. 19C, 19D. These questions included whether the attacker had
used weapons or threats, whether there was any “grabbing, grasping, or holding”
during the incident, whether penetration occurred, whether contraception was used,
K.E.H.’s position during the assault, and K.E.H.’s pain level and areas of pain. 6
VTP (Nov. 3, 2016) at 614-21.
25
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
Although these statements may have been relevant to medical treatment, the
primary purpose of the questions Frey posed in the context of this sexual assault
examination was “to establish or prove past events potentially relevant to later
criminal prosecution.” Davis, 547 U.S. at 822. The objective manifestations of
forensic intent evidenced by both parties, the specific history and purpose of SANE
nursing, the lack of ongoing emergency, and the high level of formality of the
exam make this clear. Thus, admission of all of these out-of-court statements—not
just the statement of identity cited by the majority—violated the confrontation
clause.
A violation of the Sixth Amendment is constitutional error. A constitutional
error is harmless only if the State proves “beyond a reasonable doubt [that] any
reasonable jury would reach the same result absent the error, and where the
untainted evidence is so overwhelming it necessarily leads to a finding of guilt.”10
Ronald Burke was charged with rape in the second degree, which required
the jury to find beyond a reasonable doubt that he had engaged in sexual
intercourse by forcible compulsion with K.E.H. Clerk’s Papers at 85. Here, even
10
State v. Easter, 130 Wn.2d 228, 242, 922 P.2d 1285 (1996) (citation omitted)
(citing State v. Aumick, 126 Wn.2d 422, 430, 894 P.2d 1325 (1995); State v. Whelchel,
115 Wn.2d 708, 728, 801 P.2d 948 (1990)); see Chapman v. California, 386 U.S. 18, 24,
87 S. Ct. 824, 17 L. Ed. 2d 705 (1967).
26
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
without K.E.H.’s statements, the jury was presented with overwhelming evidence
that sexual intercourse had occurred. Evidence of semen was found in K.E.H.’s
underwear. 7 VTP (Nov. 7, 2016) at 723. K.E.H.’s genital exam also revealed
evidence consistent with sexual intercourse. 6 VTP (Nov. 3, 2016) at 641, 643.
I agree with the majority that the jury also heard overwhelming evidence
that Burke was the source of the semen. Evidence was introduced that Burke lived
near Wright Park in 2009 and had been to the park. 8 VTP (Nov. 8, 2016) at 807-
08. Prior to describing the assailant to Frey, K.E.H. had described his appearance
to an investigating officer after she arrived at the hospital on the night of July 3,
2009. Id. at 843. Later, a DNA sample obtained from K.E.H.’s underwear during
the forensic exam was matched to Burke’s DNA, and the jury heard detailed
testimony from a DNA analyst explaining the very low likelihood that the DNA
belonged to anyone other than Burke. 7 VTP (Nov. 7, 2016) at 745; see majority at
30-31. Thus, the admission of the testimonial statements was harmless as to
Burke’s identity and the fact of intercourse.
The State also presented overwhelming evidence of forcible compulsion
even without K.E.H.’s testimonial statements. K.E.H. showed up at the hospital
late at night, “very upset” and crying, with “leaves and grass in her hair.” 8 VTP
(Nov. 8, 2016) at 855. She reported to an ER nurse and a social worker that she
27
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
had been raped in Wright Park, and the admissibility of these statements has not
been challenged. 7 VTP (Nov. 7, 2016) at 689; 8 VTP (Nov. 8, 2016) at 856.
K.E.H. described her assailant and the place in the park where the attack had
occurred to the officer who was dispatched to the hospital, and those statements
were also admitted without objection. 8 VTP (Nov. 8, 2016) at 841. The defendant
did not testify; K.E.H.’s testimony on these points was undisputed.
In the unchallenged portion of her testimony, Frey also described her
observations of K.E.H., including injuries she documented during the forensic
examination. K.E.H. had suffered a cervical laceration which was still “actively
bleeding.” 6 VTP (Nov. 3, 2016) at 643. Frey testified that having done hundreds
of pelvic exams over the course of her career, this type of cervical injury was very
unusual. Id. In fact, she testified that she had never seen this type of cervical injury
occurring even with forcible consensual sex. Id. at 659. Thus, Frey testified that the
cervical laceration was consistent with forcible, nonconsensual intercourse. Id. at
643 (“I would say ‘no’ to this being a consensual thing. It’s hard to do this to a
tough muscle.”). This was so even considering K.E.H.’s postmenopausal status and
28
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
the possibility that she could have been suffering from the beginning stages of the
cervical cancer that was a probable cause of her 2011 death. Id. at 657, 660-63. 11
Based on the properly admitted evidence, the State proved beyond a
reasonable doubt that admission of the testimonial statements was harmless.
III. Conclusion
SANEs provide an extremely valuable service to survivors of sexual assault.
But that does not mean that out-of-court statements SANEs elicit from patients are
exempt from confrontation clause analysis. Instead, the federal constitution
requires courts to analyze the out-of-court statements SANEs elicit from survivors
or witnesses the same way that courts analyze out-of-court statements that other
forensic professionals elicit from other complainants or witnesses. Courts must
place primary emphasis on context. The context includes the development of the
SANE medical/forensic field in the first place, the professional forensic training
SANEs receive, the forensic functions that they perform, and the State’s statutory
11
Frey testified that the cervical injury was unlikely to have been caused by any
postmenopausal changes in lubrication, stating that the cervix continues to be “pretty
active in terms of lubrication” even in postmenopausal women like K.E.H. 6 VTP (Nov.
3, 2016) at 657. Thus, even with lubrication issues, “you would see vaginal injuries more
commonly than anything on the cervix.” Id. at 658. Although Frey testified that cervical
cancer “could” make the cervix more vulnerable to injury, she also stated that at the time
of the exam, K.E.H. did not have end-stage cervical cancer based on the appearance of
her cervix. Id. at 660, 662.
29
State v. Burke (Ronald Delester), No. 96783-1
(Gordon McCloud, J., concurring)
financial support for those forensic functions in evaluating individual statements.
The majority fails to adequately consider that the primary purpose of this forensic
examination, under the totality of the circumstances, was “to establish or prove
past events potentially relevant to later criminal prosecution.” Davis, 547 U.S. at
822.
I therefore respectfully concur.
_____________________________________
_____________________________________
_________________________________
Mann, J.P.T.
30