Title: Commonwealth v. LaBrie

State: massachusetts

Issuer: Massachusetts Supreme Court

Document:

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SJC-11836 
 
COMMONWEALTH  vs.  KRISTEN A. LaBRIE. 
 
 
 
Essex.     November 2, 2015. - March 9, 2016. 
 
Present:  Gants, C.J., Spina, Cordy, Botsford, Duffly, Lenk, & 
Hines, JJ. 
 
 
Attempt.  Homicide.  Assault and Battery.  Reckless Endangerment 
of a Child.  Intent.  Evidence, Intent.  Practice, 
Criminal, Assistance of counsel. 
 
 
 
 
Indictments found and returned in the Superior Court 
Department on July 3, 2009. 
 
 
The cases were tried before Richard E. Welch, III, J., and 
a motion for a new trial, filed on June 6, 2013, was heard by 
him. 
 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
 
Michelle Menken for the defendant. 
 
Marcia H. Slingerland, Assistant District Attorney (Kate 
Berrigan MacDougall, Assistant District Attorney, with her) for 
the Commonwealth. 
 
 
 
BOTSFORD, J.  The defendant, Kristin LaBrie, was charged 
with the attempted murder of her young son and related assault 
2 
 
and battery and child endangerment crimes.  The Commonwealth 
contends that the defendant, with the intent to kill her son, 
did not give him prescribed chemotherapy and other medications 
designed to treat the cancer from which he suffered and 
ultimately died.  At a trial before an Essex County jury, the 
defendant was convicted on these charges; before us is her 
appeal from these convictions and also from the denial of her 
motion for a new trial.  The defendant claims that her 
conviction of attempted murder must be reversed because the 
Commonwealth was required, and failed, to prove that the 
substantive crime of murder was not achieved, and because the 
judge's instructions to the jury on this crime were erroneous.  
She further claims that the evidence also was insufficient to 
permit convictions of the two assault and battery charges, and 
again that the judge's instructions were legally incorrect.  
Finally, the defendant argues that the judge erred in denying 
her motion for a new trial and in particular in rejecting her 
claims concerning the ineffective assistance provided by trial 
counsel.  For the reasons discussed below, we affirm the 
defendant's conviction of reckless endangerment of a child under 
G. L. c. 265, § 13L; reverse the judgments on both assault and 
battery charges and order judgment for the defendant on those 
charges; and reverse the order denying the defendant's motion 
for a new trial on the charge of attempted murder. 
3 
 
 
Background.  1.  Factual background.  The jury could have 
found the following facts.  The defendant had a son, Peter,1 the 
victim, who in 2006 was seven years old and presented with 
significant medical and physical concerns.2  In October, 2006, 
Peter was brought to the Massachusetts General Hospital 
(hospital) on an emergency basis and diagnosed with 
lymphoblastic lymphoma, a cancer of the lymph nodes.3  At the 
time of the diagnosis, the defendant was separated from Eric 
Fraser, her former husband and Peter's father, and the defendant 
was Peter's primary caretaker.4 
 
Dr. Alison Friedmann, a pediatric hematologist-oncologist 
at the hospital, led the treatment team for the cancer from the 
point of Peter's first admission and became Peter's primary 
physician throughout treatment.  When Peter was first diagnosed, 
Friedmann explained to the defendant the diagnosis, the survival 
rate, and an overview of the proposed treatment plan for Peter.  
The plan consisted of five phases over two years, combining in-
hospital and at-home treatment.  It included a complicated 
                     
 
1 A pseudonym. 
 
 
2 Peter was severely autistic and did not speak, had severe 
developmental delay, and also had a history of seizures. 
 
 
3 Lymphoblastic lymphoma is a form of non-Hodgkin's 
lymphoma. 
 
 
4 The defendant was the primary caretaker until March, 2008, 
when Eric Fraser obtained full custody of Peter. 
4 
 
chemotherapy regimen that used many different medications in 
differing schedules and required heavy parental involvement.  
With treatment pursuant to that plan, the long-term survival 
rate for children with lymphoblastic lymphoma is about eighty-
five to ninety per cent.5 
 
In the first phase of the treatment ("induction" phase), in 
which the goal was to put the cancer into remission, Peter was 
hospitalized for two weeks and then treated at home for the next 
two weeks.  During the home treatment portion of this phase, the 
defendant was responsible for giving Peter an oral medication, 
dexamethasone, a steroid that is an important part of the 
treatment.  The defendant was to administer dexamethasone 
beginning in approximately November of 2006.  Pharmacy records 
indicate that this prescription was not filled until April, 
2007.6  It appears that Peter achieved remission of the cancer by 
the end of this first phase. 
 
In phases two ("consolidation" phase) and three ("inner 
maintenance" or "delayed intensification" phase) of the 
treatment, Friedmann prescribed another oral chemotherapy agent, 
                     
 
5 "Long-term survival," according to Dr. Alison Friedmann, 
means that the child is cured of the disease and it never 
recurs. 
 
 
6 According to Friedmann, the defendant filled the 
prescriptions at a certain pharmacy in Peabody only; however, 
the defendant testified that she picked up the prescriptions 
related to the first phase from the hospital. 
5 
 
6-mercaptopurine (6-MP).  The defendant was responsible for 
giving Peter 6-MP every night beginning in or about early 
December, 2006, and was to continue for three or four months.  
Pharmacy records indicate that this prescription was not filled 
until June 28, 2007.  Nonetheless, in the winter or early spring 
of 2007, the defendant told Friedmann she was having a hard time 
giving Peter the 6-MP, and the doctor changed the prescription 
to a liquid form.  The third phase required planned hospital 
stays to receive chemotherapy as an inpatient, along with 
continued at-home administration of 6-MP. 
 
Throughout the first three phases of Peter's treatment, a 
home care nurse from the hospital visited the defendant and 
Peter on a regular basis.  During the first month of treatment 
the nurse traveled to the defendant's home once or twice per 
week and thereafter visited when blood tests were needed.  
During these visits, the home care nurse reviewed the plan of 
care and answered any questions the defendant had about 
administering the medications.  During the fall of 2006 into the 
winter of 2007, the home care nurse asked the defendant if she 
had given Peter the medications and the defendant reported that 
Peter was taking his medications.  The defendant also reported 
to Friedmann that generally "things seemed to be going okay," 
and aside from letting Friedmann know she was having trouble 
6 
 
giving Peter the 6-MP, she never indicated there were any 
difficulties giving Peter the medications. 
 
The fourth phase ("reinduction" phase), which started in 
the spring of 2007, involved intravenous medications in the 
clinic and oral steroids.  Peter had weekly visits with 
Friedmann during which the doctor checked his blood, reviewed 
the medications with the defendant, and discussed how Peter was 
doing.  During this phase, the entirety of the chemotherapy was 
administered at the hospital and, according to the pharmacy 
records, the oral medication prescription was filled. 
 
The final phase of treatment ("maintenance" phase) began at 
the end of June, 2007, and was intended to continue for sixteen 
months.  This phase involved three medications, including 6-MP, 
that were to be given to Peter by the defendant at home and one 
medication that was to be administered intravenously during a 
monthly visit to the hospital.  Although the 6-MP prescription 
was supposed to be refilled every month and administered nightly 
during this final phase, the monthly prescription was only 
filled on June 28, 2007; September 5, 2007; and January 30, 
2008.  In August, 2007, the defendant told the home care nurse 
that "the medications were going good," Peter was tolerating 
them, and she had no concerns.  Although she never filled the 
prescription for the liquid form of 6-MP, the defendant further 
7 
 
reported to the home care nurse that Peter was taking the liquid 
form of 6-MP, and "it was going better."7 
 
During a clinic visit in February, 2008, Peter had a bad 
cough and fever and his platelet count was lower; he was 
diagnosed with influenza and the respiratory syncytial virus.  
Friedmann was worried about a relapse, instructed the defendant 
to stop his chemotherapy medicine, and prescribed an antiviral 
medication to treat influenza.  The defendant told the home care 
nurse that she was not giving Peter the antiviral medication 
because she did not want to make him sick.  The nurse attempted 
to schedule an appointment for the end of that week to draw 
Peter's blood, but the defendant was unavailable.  Because it 
struck Friedmann as "odd" that the hospital was unable to obtain 
the blood test, she telephoned the pharmacy to determine whether 
Peter's prescriptions had been filled as prescribed.  The 
records revealed that the defendant had not filled multiple 
medications prescribed to Peter throughout the treatment period.8  
The doctor telephoned the defendant and told her they "really 
needed to get some lab tests done."  When the defendant brought 
                     
 
7 Throughout the treatment, the defendant brought Peter in 
for all of his doctor's appointments and for all of his 
outpatient and inpatient hospital treatments; on a few 
occasions, Peter missed an appointment, but the defendant 
brought him in within a few days of the scheduled appointment. 
 
 
8 Friedmann testified at trial that multiple breaks in 
chemotherapy treatment are "very significant." 
8 
 
Peter to the hospital the next day, the doctor discovered that 
Peter had suffered a relapse, meaning that the cancer had 
returned.9  Friedmann asked the defendant about the missed 
prescriptions, but the defendant insisted that the pharmacy must 
have made a mistake.  After the pharmacy confirmed that no 
mistake had been made, Friedmann and a social worker at the 
hospital filed a report of child abuse or neglect with the 
Department of Children and Families (DCF) pursuant to G. L. 
c. 119, § 51A. 
 
During a meeting with a DCF social worker after that report 
had been filed, the defendant claimed that she had administered 
all of the medications prescribed, and at some point stated to 
the social worker that she knew withholding Peter's medicine 
would be "like pushing him in front of a car."  At the end of 
March, 2008, Fraser obtained custody of Peter, and in April the 
defendant signed a stipulation rescinding her visitation rights 
with Peter and agreeing to give Fraser full custody of him.  
After it was confirmed that Peter had relapsed, Friedmann 
explained to the defendant and Fraser that the cancer could not 
be treated with the original treatment because the cancer was 
now resistant to that treatment; the only viable treatment was a 
bone marrow transplant, a complicated procedure with a low 
                     
 
9 Peter's cancer at this time was leukemia (cancer of the 
blood and bone marrow), as compared to the earlier diagnosis of 
lymphoma (cancer of the lymph nodes). 
9 
 
chance of survival.  Peter's parents decided against the bone 
marrow transplant, and it became clear that continued treatment 
would only control the cancer but could not cure it; thereafter, 
chemotherapy was suspended.  Peter died on March 30, 2009, of 
respiratory failure secondary to acute lymphoblastic leukemia. 
 
The Commonwealth's theory was that the defendant understood 
that not giving Peter the prescribed medications would create a 
substantial risk of death, that she made an intentional decision 
to withhold the medications from Peter because she wanted to 
kill him, and that she repeatedly lied in order to conceal her 
ongoing efforts to kill her son.  It was not possible to 
determine -- according to Friedmann -- whether the defendant's 
noncompliance with the medication protocol caused Peter's cancer 
to return (and therefore his death), but the defendant's 
noncompliance created a significant risk that the cancer would 
do so. 
 
The theory of the defense was that the defendant's failure 
to administer Peter's medications10 was done without any intent 
to kill her son.  Rather, the short-term effect of the 
chemotherapy treatment was simply too burdensome for a single 
caretaker such as the defendant, and she was so fatigued by the 
end of the treatment that her judgment waned.  The defendant 
                     
 
10 At trial, the defendant admitted that she failed to give 
Peter various medications during treatment. 
10 
 
testified to this effect, as did Dr. Frederick Krell, a forensic 
psychologist who testified as an expert witness for the defense.  
Krell opined that the defendant was overwhelmed with having to 
cope with an impaired child who had a life-threatening illness, 
and she was unable to keep in mind the long-range goal of the 
treatment.  In response, the Commonwealth called Dr. Martin 
Kelly, a psychiatrist, who testified that the defendant did "not 
have any mental disorder or psychological condition that would 
affect her capacity to premeditate, to weigh the pros and cons, 
to intend to do the acts that she did." 
 
2.  Procedural background.  In July, 2009, the defendant 
was indicted on charges of attempted murder, G. L. c. 265, § 16; 
wantonly or recklessly permitting substantial bodily injury to a 
child under the age of fourteen, G. L. c. 265, § 13J (b); 
wantonly or recklessly permitting serious bodily injury to a 
disabled person, G. L. c. 265, § 13K (e); and wantonly or 
recklessly endangering a child, G. L. c. 265, § 13L.  In April, 
2011, at the end of trial, a jury found the defendant guilty of 
all four charges.11  The defendant filed a timely notice of 
appeal and, represented by her present appellate counsel, 
subsequently filed a motion for a new trial that included claims 
                     
 
11 The defendant was sentenced to a term of from eight to 
ten years on the conviction of attempted murder, and concurrent 
five-year terms of probation on the remaining convictions, to be 
served from and after the prison sentence. 
11 
 
of ineffective assistance of trial counsel.  The trial judge 
held an evidentiary hearing on the ineffective assistance claims 
at which three witnesses testified.  Following the hearing, the 
judge denied the defendant's motion for a new trial.  On 
November 27, 2013, the defendant filed a notice of appeal from 
this denial, and the appeals were consolidated.  We transferred 
the case to this court on our own motion. 
 
Discussion.  1.  Attempted murder:  nonachievement.  The 
defendant challenges the sufficiency of the evidence for her 
conviction of attempted murder.  She argues that the crime of 
attempted murder, like the crime of general attempt, has three 
elements:  (1) a specific intent to kill, (2) an overt act, and 
(3) nonaccomplishment or nonachievement of the completed crime.  
In her view, the Commonwealth was required to prove all three of 
these elements beyond a reasonable doubt and argues that because 
the Commonwealth, by its own admission, was unable to prove 
nonachievement, her motion for a required finding of not guilty 
should have been allowed.12  Alternatively, she contends that 
even if the trial evidence were sufficient to preclude a 
required finding on the element of nonachievement, the judge's 
failure to include any instruction on this element meant that 
the jury did not consider whether the Commonwealth presented 
                     
 
12 For the purposes of this argument, the defendant does not 
challenge the sufficiency of the evidence of intent to kill and 
of an overt act. 
12 
 
sufficient evidence, creating a substantial risk of a 
miscarriage of justice.  We disagree.  For the reasons next 
discussed, we conclude that specific intent and commission of an 
overt act are the required elements of the crime of attempt or, 
here, attempted murder, but that nonachievement of the murder, 
while clearly relevant, is not itself an element that the 
Commonwealth must prove beyond a reasonable doubt. 
 
The crime of attempted murder is defined in G. L. c. 265, 
§ 16,13 and is distinct from the crime of general attempt, G. L. 
c. 274, § 6.14  Notwithstanding the differences in the language, 
our cases have tended to treat the elements of attempt as the 
same under both statutes.  See Commonwealth v. Peaslee, 177 
Mass. 267 (1901) (attempt to burn building); Commonwealth v. 
Kennedy, 170 Mass. 18 (1897) (attempted murder).  It is also the 
case that attempted murder may be prosecuted as an attempt under 
c. 274, § 6, rather than c. 265, § 16.  See, e.g., Commonwealth 
v. Dixon, 34 Mass. App. Ct. 653, 655 (1993). 
                     
 
13 General Laws c. 265, § 16, provides in relevant part: 
 
 
"Whoever attempts to commit murder by poisoning, drowning 
or strangling another person, or by any means not 
constituting an assault with intent to commit murder, shall 
be punished . . . ." 
 
 
14 General Laws c. 274, § 6, provides in relevant part: 
 
"Whoever attempts to commit a crime by doing any act toward 
its commission, but fails in its perpetration, or is 
intercepted or prevented in its perpetration, shall, except 
as otherwise provided, be punished . . . ." 
13 
 
 
This case appears to be the first in which this court has 
considered directly whether nonachievement is an element of 
attempted murder, or more generally, attempt.  Unquestionably, 
the defendant's argument that nonachievement is an element of 
attempt crimes is not without support:  a number of cases 
arising under the general attempt statute have included 
nonachievement as an element of attempt.  See, e.g., 
Commonwealth v. Marzilli, 457 Mass. 64, 66 (2010) (attempted 
indecent assault and battery); Commonwealth v. Bell, 455 Mass. 
408, 412 (2009) (attempted rape).  And the Appeals Court has 
recognized a form of nonachievement -- "failure or interruption" 
-- as an element of attempted murder under G. L. c. 265, § 16.  
See, e.g., Commonwealth v. Murray, 51 Mass. App. Ct. 57, 61 
(2001); Dixon, 34 Mass. App. Ct. at 655.  In contrast to this 
case, however, in all of the cited cases the question whether 
the substantive crime was completed was not at issue -- there 
was no disagreement that it had not been achieved -- and the 
element of nonachievement was not substantively discussed.  
Moreover, a number of other cases decided by this court and the 
Appeals Court suggest that the elements of attempt are limited 
to the requisite intent and an overt act.  See, e.g., 
Commonwealth v. Rivera, 460 Mass. 139, 142 (2011); Commonwealth 
v. Ortiz, 408 Mass. 463, 470 (1990); Commonwealth v. Gosselin, 
365 Mass. 116, 120-121 (1974); Commonwealth v. Cline, 213 Mass. 
14 
 
225, 225 (1913); Commonwealth v. Sullivan, 84 Mass. App. Ct. 26, 
28-30 (2013), S.C., 469 Mass. 621 (2014). 
 
This court's jurisprudence on attempt dates back to 
Kennedy, 170 Mass. 18, a decision authored by then Justice 
Holmes, that considered a case of attempted murder brought under 
an earlier version of G. L. c. 265, § 16; and Peaslee, 177 Mass. 
267, authored by then Chief Justice Holmes, concerning an 
attempt to burn a building under an earlier version of G. L. 
c. 274, § 6.  In Kennedy, supra, the defendant was charged with 
attempted murder by placing deadly poison on the victim's cup 
with the intent that the victim drink from the cup, ingest the 
poison, and die.  Id. at 20.  Although it is clear from the 
opinion that the victim did not die as a result of the 
defendant's acts, see id. at 23, the fact is of little 
significance in the court's discussion of the nature of the 
crime.  Rather, the court focused principally on the nature of 
the overt act or acts taken by the defendant toward 
accomplishment of the intended murder.15  With respect to the 
overt acts, Justice Holmes emphasized that not all acts leading 
toward the substantive crime are subject to punishment as a 
criminal attempt, but only those that come "near enough to the 
result," i.e., accomplishment of the substantive crime: 
                     
 
15 The court made clear that the evidence of the defendant's 
intent to kill the victim was sufficient.  Commonwealth v. 
Kennedy, 170 Mass. 18, 25 (1897). 
15 
 
"[W]e assume that an act may be done which is expected and 
intended to accomplish a crime, which is not near enough to 
the result to constitute an attempt to commit it, as in the 
classic instance of shooting at a post supposed to be a 
man.  As the aim of the law is not to punish sins, but is 
to prevent certain external results, the act done must come 
pretty near to accomplishing that result before the law 
will notice it." 
 
Id. at 20.  See id. at 22 ("Every question of proximity must be 
determined by its own circumstances . . .").  See also Peaslee, 
177 Mass. at 271 ("The question on the evidence, . . . precisely 
stated, is whether the defendant's acts come near enough to the 
accomplishment of the substantive offence to be punishable").16 
 
Kennedy and Peaslee explain and illustrate that the essence 
of the crime of attempt is to punish the defendant's substantial 
acts toward the accomplishment of an intended substantive 
offense.  See Commonwealth v. Burns, 8 Mass. App. Ct. 194, 196 
                     
 
16 The court in Commonwealth v. Peaslee, 177 Mass. 267, 272 
(1901), continued in further explanation: 
 
"That an overt act although coupled with an intent to 
commit the crime commonly is not punishable if further acts 
are contemplated as needful, is expressed in the familiar 
rule that preparation is not an attempt.  But some 
preparations may amount to an attempt.  It is a question of 
degree.  If the preparation comes very near to the 
accomplishment of the act, the intent to complete it 
renders the crime so probable that the act will be a 
misdemeanor although there is still [an opportunity to 
change one's mind] in the need of a further exertion of the 
will to complete the crime." 
 
The court concluded that at least the acts alleged in the 
indictment, collection and preparation of combustible materials 
in a room, by themselves did not come near enough to the 
accomplishment of the substantive offense of burning (arson) to 
be punishable.  See id. at 273-274. 
16 
 
(1979).  See also R.M. Perkins, Criminal Law, at 552 (2d ed. 
1969).  The substantive crime is clearly both relevant and 
important, because what the crime of attempt aims to punish are 
acts that bear a proximate relation to that crime; put another 
way, the substantive crime helps to define and delimit what acts 
may have the requisite proximity.  But the acts stand on their 
own, and whether a particular act qualifies as an overt act 
that, combined with proof of the requisite intent, constitutes a 
criminal attempt does not depend on whether the substantive 
crime has or has not been accomplished.17 
 
In contending that nonaccomplishment is an element of 
attempt that the Commonwealth must prove, the defendant relies 
principally on cases such as Marzilli, 457 Mass. at 66, and 
Bell, 455 Mass. at 412.18  In these decisions, as previously 
                     
 
17 By way of example, in Kennedy, 170 Mass. at 21-22, the 
Commonwealth's failure to prove that the amount of poison placed 
on the cup was "large enough to kill" was of no import to the 
defendant's liability under the law of attempted murder: 
 
"Any unlawful application of poison is an evil which 
threatens death, according to common apprehension, and the 
gravity of the crime, the uncertainty of the result, and 
the seriousness of the apprehension, coupled with the great 
harm likely to result from poison even if not enough to 
kill, would warrant holding the liability for an attempt to 
begin at a point more remote from the possibility of 
accomplishing what is expected than might be the case with 
lighter crimes." 
 
Id. at 22. 
18 The defendant also relies on Beale, Criminal Attempts, 16 
Harv. L. Rev. 491 (1903). 
17 
 
mentioned, the court listed nonachievement as an element of 
attempt, but did not otherwise discuss it.  Both these cases 
involved the general attempt statute, G. L. c. 274, § 6, which 
contains language that focuses specifically on failing to 
accomplish, or being prevented from accomplishing, the 
substantive crime.19  On reflection, we consider this language to 
represent not a separate element of the crime of attempt but "a 
further refinement of the definition of the overt act."  
Commonwealth v. Aldrich (No. 1), 88 Mass. App. Ct. 113, 118 
(2015).  That is, the language helps to clarify and reinforce 
the point that attempt is a crime separate and distinct from the 
substantive offense to which it is connected, one that focuses 
on, and punishes, acts that threaten the accomplishment of the 
substantive offense, not the substantive offense itself.  
Accordingly, to the extent that our decisions such as Marzilli 
and Bell indicate that proof of nonachievement of the 
substantive crime is an element of attempt, we no longer follow 
                                                                  
 
 
19 "Whoever attempts to commit a crime by doing any act 
toward its commission, but fails in its perpetration, or is 
intercepted or prevented in its perpetration, shall . . . be 
punished . . ." (emphasis added).  G. L. c. 274, § 6.  The 
statute defining attempted murder, G. L. c. 265, § 16, does not 
contain this language, but as discussed previously, we take the 
view that the essential elements of "attempt" are the same in 
both statutes. 
18 
 
them.20  The elements of attempt, whether general attempt or 
attempted murder, are (1) the specific intent to commit the 
substantive crime at issue, and (2) an overt act toward 
completion of the substantive crime.21 
 
Here, the Commonwealth is not able to prove beyond a 
reasonable doubt either that the defendant murdered Peter or 
that the defendant failed to murder him.  We agree, as does the 
Commonwealth, that in these circumstances, the defendant cannot 
be convicted of murder.  But "requiring the government to prove 
failure as an element of attempt would lead to the anomalous 
result that, if there were a reasonable doubt concerning whether 
or not a crime had been completed, a jury could find the 
defendant guilty neither of a completed offense nor of an 
attempt."  United States v. York, 578 F.2d 1036, 1039 (5th 
Cir.), 439 U.S. 1005 (1978).  See Gosselin, 365 Mass. at 120 
                     
 
20 The Appeals Court recently has concluded that under the 
general attempt statute, "the completed substantive offense 
nullifies the existence of an attempt."  Commonwealth v. Coutu, 
88 Mass. App. Ct. 686, 701 (2015).  See Beale, Criminal 
Attempts, 16 Harv. L. Rev. at 506-507.  There is no need for us 
to consider this issue in the present case, because, quite apart 
from the fact that the general attempt statute does not apply, 
the Commonwealth admittedly did not and could not prove 
completion of the substantive offense. 
 
 
21 Commonwealth v. Dykens, 473 Mass. 635 (2015), is not to 
the contrary.  In that case, we considered whether three 
successive failures to break into a dwelling could be prosecuted 
as three separate attempts.  With respect to each of these 
attempts, the failure served to delimit the attempt's overt act, 
but the failure was not itself an element of the offense. 
19 
 
(stating, in dictum, that requiring proof beyond reasonable 
doubt that attempt failed would mean that "if there were a 
reasonable doubt whether the attempt succeeded, the defendant 
could not be convicted either of the completed crime or of the 
attempt.  We have rejected such requirements").  See also United 
States v. Rivera-Relle, 333 F.3d 914, 919-921 (9th Cir.), cert. 
denied, 540 U.S. 977 (2003) (failure to complete entry into 
United States was not element of offense of attempting to 
reenter United States without consent of Attorney General; 
discussing Federal and State decisions on whether nonachievement 
must be proved as element of attempt); Lightfoot v. State, 278 
Md. 231, 238 (1976) (where no joint venture theory existed, 
robbery was complete, but uncertainty existed about whether 
defendant himself had completed robbery, defendant charged with 
attempted robbery because "failure to consummate the crime is 
not an indispensable element of criminal attempt"). 
 
Our conclusion that nonachievement of murder is not an 
element of attempted murder essentially disposes of the 
defendant's challenge to the judge's instructions on this crime.  
The judge instructed the jury that the Commonwealth "[does not] 
have to prove that the defendant caused the death of [Peter].  
It's instead attempted murder, that is she had the intent with 
malice and then she makes some overt act toward the murder 
. . . .  Attempted murder only exists if there's not an actual 
20 
 
murder, of course."  The judge further instructed the jury on 
the element of an overt act, stating that they must find "some 
actual outward physical action as opposed to mere talk or plans. 
. . .  [A]n act . . . that is reasonably expected to bring about 
the crime [of murder]."  We conclude that the judge's 
instructions correctly explained the elements of attempted 
murder. 
 
2.  Assault and battery charges.  The defendant challenges 
her convictions of assault and battery upon a child, in 
violation of G. L. c. 265, § 13J (b), fourth par. (§ 13J [b], 
fourth par.); and of assault and battery upon a person with a 
disability, in violation of G. L. c. 265, § 13K (e) (§ 13K [e]).  
Section 13J (b), fourth par., punishes a caretaker of a child 
who "wantonly or recklessly permits substantial bodily injury" 
to the child,22 and § 13K (e) punishes a caretaker of a person 
with a disability who "wantonly or recklessly permits serious 
bodily injury" to the person with a disability.23,24  The 
                     
 
22 General Laws c. 265, § 13J (b), fourth par. (§ 13J [b], 
fourth par.), provides in relevant part: 
 
"Whoever, having care and custody of a child, wantonly or 
recklessly permits substantial bodily injury to such child 
or wantonly or recklessly permits another to commit an 
assault and battery upon such child, which assault and 
battery causes substantial bodily injury, shall be punished 
. . . ." 
 
 
23 General Laws c. 265, § 13K (e) (§ 13K [e]), provides in 
pertinent part: 
21 
 
defendant contends that although the Commonwealth may have 
presented sufficient evidence to prove that the defendant caused 
a substantial risk of death to Peter by not giving him the 
prescribed chemotherapy and related medications, it did not 
present evidence sufficient to prove "substantial bodily 
injury."  She further argues that the judge's instructions to 
the jury incorrectly defined the meaning of substantial bodily 
injury.25  We agree with the defendant on both points. 
                                                                  
 
"Whoever, being a caretaker of [a] . . . person with a 
disability, wantonly or recklessly permits serious bodily 
injury to such . . . person with a disability . . . shall 
be punished . . . ." 
 
 
24 Section § 13J (b), fourth par., concerns "substantial 
bodily injury" to a "child," and § 13K (e) concerns "serious 
bodily injury" to a "person with a disability."  In this case, 
the Commonwealth’s position is that Peter fit the definition of 
"child" in the first of these statutes, and of "person with a 
disability" in the second.  The defendant does not argue 
otherwise, and we agree.  We have previously concluded that the 
definitions of "substantial bodily injury" in § 13K (b) and 
"serious bodily injury" in § 13K (e) are substantively the same.  
See Commonwealth v. Roderiques, 462 Mass. 415, 423 n.2 (2012).  
Because of this, and because the remaining provisions in the two 
statutes are also substantively identical, for ease of 
reference, the discussion in the text that follows considers 
only the charge under § 13J (b), fourth par., but the discussion 
applies equally to the charge under § 13K (e). 
 
 
25 At trial, the defendant moved for a required finding of 
not guilty on both these charges, arguing that the Commonwealth 
failed to prove the defendant had caused actual bodily injury to 
Peter.  The trial judge denied the defendant's motion for a 
required finding of not guilty, explaining that under the common 
law the defendant's argument might be sound, but under the 
statutory causes of action at issue proof of a substantial risk 
22 
 
 
The term "[b]odily injury" is defined in G. L. c. 265, 
§ 13J (a), as a 
"substantial impairment of the physical condition including 
any burn, fracture of any bone, subdural hematoma, injury 
to any internal organ, any injury which occurs as the 
result of repeated harm to any bodily function or organ 
including human skin or any physical condition which 
substantially imperils a child's health or welfare." 
 
The term "[s]ubstantial bodily injury" is defined in the same 
section to mean "bodily injury which creates a permanent 
disfigurement, protracted loss or impairment of a function of a 
body member, limb or organ, or substantial risk of death."  We 
previously have stated, in discussing § 13J (b), fourth par., 
that 
"[the term 'bodily injury'] defines the bodily injuries the 
Legislature intended to be punishable under the statute, 
i.e., burns, fractures, injuries to internal organs, and 
perilous physical conditions, while ['substantial bodily 
injury'] lays the foundation for greater sanctions based on 
the gravity and consequences of the bodily injury 
sustained.  Read together, . . . a substantial bodily 
injury includes any substantial impairment of the physical 
condition that causes a protracted impairment of the 
function of an internal organ or a substantial risk of 
death.  As it appears in the context of the statute, death 
is not an injury, but one risk of injury." 
 
Commonwealth v. Chapman, 433 Mass. 481, 484 (2001).  See 
Commonwealth v. Roderiques, 462 Mass. 415, 423 (2012) 
("substantial bodily injury" under § 13J [b], fourth par., 
                                                                  
of death was sufficient.  The jury instructions reflected the 
judge's stated understanding of the law. 
23 
 
requires risk of injury to "come to fruition in the form of an 
actual injury"). 
 
The evidence at trial permitted the jury to find, based on 
Friedmann's testimony, that the defendant's failure or refusal 
to give Peter the medications that were part of his treatment 
plan caused an increased risk of death for Peter.  However, if 
death itself does not qualify as a "bodily injury" or "serious 
bodily injury" under the statute, see Chapman, 433 Mass. at 484, 
neither does an increased risk of death.  The Commonwealth 
asserts, however, that the defendant's withholding of 
medications led to Peter's cancer returning in a more virulent 
and treatment-resistant form, and that this more potent illness 
was itself a "bodily injury" that, in the words of § 13J (b), 
fourth par., the defendant wantonly or recklessly permitted to 
occur.26 
 
The Commonwealth's argument fails.  Although the presence 
of a stronger, more treatment-resistant form of cancer may 
qualify as a "bodily injury" under the statutory definition, see 
G. L. c. 265, § 13J (a) ("bodily injury" defined to include "any 
physical condition which substantially imperils a child's health 
                     
 
26 The evidence that the Commonwealth appears to rely on was 
the following.  In responding to a question by the prosecutor as 
to whether Peter's receipt of some but not all his medications 
affected her ability to treat him once he relapsed, Friedmann 
responded, "Yes.  I believe that likely made the chemotherapy 
less effective the second time around and the leukemia more 
resistant." 
24 
 
or welfare"), an opinion that a particular result is "likely" 
does not appear to be sufficient to permit a finding that the 
defendant's actions actually caused the more treatment-resistant 
form of cancer to occur.27  Given that, according to the 
evidence, even with full treatment ten to fifteen per cent of 
children still succumb to the cancer, just as the Commonwealth 
admittedly could not prove beyond a reasonable doubt that the 
defendant's actions caused Peter's death from cancer, so it 
appears that the Commonwealth would not be able to prove that 
the defendant's actions caused him to relapse and become ill 
with a more treatment-resistant form of cancer. 
 
We thus conclude that the trial evidence was insufficient 
to support the defendant's assault and battery convictions under 
§§ 13J (b), fourth par., and 13K (e), and those convictions must 
be vacated.28  The defendant also was convicted of reckless 
                     
 
27 Section 13J (b), fourth par., punishes a caretaker who 
"wantonly or recklessly permits substantial bodily injury to" 
the child.  The word "permits" signifies that the Commonwealth 
is not required to prove the caretaker actually inflicted the 
bodily injury -- failure to act when there is a duty to do so 
may suffice -- but the word "permits" does not remove the 
Commonwealth's burden to prove beyond a reasonable doubt the 
causal connection between the caretaker's actions or nonactions 
and the claimed substantial bodily injury. 
 
 
28 In light of our conclusion, it is not necessary to 
resolve the defendant's challenge to the jury instructions on 
the two assault and battery charges.  We agree with the 
defendant, however, that these instructions appear to be based 
on an incorrect reading of the (identical) definitions of 
"substantial bodily injury" and "serious bodily injury" in G. L. 
25 
 
endangerment of a child in violation of G. L. c. 265, § 13L.29  
She challenged that conviction as duplicative in light of her 
conviction under § 13J (b), fourth par., see Roderiques, 462 
Mass. at 424, but agrees that if the conviction under § 13J (b), 
fourth par., is vacated or reversed, the conviction under § 13L 
may stand. 
 
3.  Motion for new trial:  ineffective assistance of 
counsel.  Finally, the defendant claims that the judge abused 
his discretion by denying the defendant's motion for a new trial 
on the ground of ineffective assistance of counsel.  She argues 
that counsel was ineffective in three ways:  (1) failing to 
consult an independent oncologist;  (2) agreeing to order his 
expert witness, Krell, to turn over his records to the 
                                                                  
c. 265, §§ 13J (a) and 13K (a), respectively.  The judge's 
instructions appear to define the terms to mean "[either] bodily 
injury which results in a permanent disfigurement, protracted 
loss or impairment of bodily function, limb or organ, or a 
substantial risk of death" (emphases added).  However, we read 
the statute to define "substantial bodily injury" as a "bodily 
injury" that results in (1) a permanent disfigurement, or (2) 
protracted loss or impairment of a bodily function, limb, or 
organ, or (3) substantial risk of death.  See Instruction 6.160 
of the Criminal Model Jury Instructions for Use in the District 
Court (2009) (reckless assault and battery causing serious 
injury). 
 
 
29 General Laws c. 265, § 13L, provides in relevant part: 
 
"Whoever wantonly or recklessly engages in conduct that 
creates a substantial risk of serious bodily injury or 
sexual abuse to a child or wantonly or recklessly fails to 
take reasonable steps to alleviate such risk where there is 
a duty to act shall be punished . . . ." 
26 
 
Commonwealth's expert, Kelly;30 and (3) failing to present 
evidence concerning the defendant's history with DCF.31  We 
conclude that counsel's failure to consult an independent 
oncologist fell measurably below the standard of "an ordinary 
fallible lawyer."  Commonwealth v. Saferian, 366 Mass. 89, 96 
(1974).  In the circumstances of this case, this failure 
deprived the defendant of "an otherwise available, substantial 
ground of defense" to the charge of attempted murder.  Id. 
 
a.  Background.  Represented by new counsel on appeal -- 
her present counsel -- the defendant filed a motion for a new 
trial on June 6, 2013.  The trial judge held an evidentiary 
hearing on the motion, at which three witnesses testified on 
behalf of the defendant:  Kevin James, the defendant's trial 
counsel; Dr. Paul Pitel, a board-certified pediatric 
hematologist-oncologist; and Krell.  In addition, the affidavits 
                     
 
30 With the assent of defense counsel, a Superior Court 
judge ordered information and records relating to the defendant 
to be sent to the Commonwealth's expert, Dr. Martin Kelly.  The 
defendant's counsel directed the defendant's expert, Dr. 
Frederick Krell, to comply with the order.  Krell produced over 
200 pages of materials, including the results and raw data from 
psychological tests he had performed. 
 
 
31 The defendant's trial counsel agreed to represent her pro 
bono in the District Court at a point in time when she had been 
charged only with reckless endangerment of a child under G. L. 
c. 265, § 13L.  Trial counsel continued to represent the 
defendant in the Superior Court when she was later indicted for 
attempted murder and two charges of assault and battery.  This 
was trial counsel's first criminal case in the Superior Court 
and first criminal case in which a mental health defense was 
asserted. 
27 
 
of trial counsel and Pitel that had been filed in support of the 
motion for a new trial were introduced in evidence as motion 
exhibits. 
 
At the motion hearing, James testified that he sought funds 
to retain an independent oncologist in order to rebut the 
testimony of Friedmann, a key witness for the Commonwealth's 
case, but later decided not to consult an oncologist on the 
grounds that (1) an effort to establish that the failure to 
medicate was harmless would be unsuccessful, especially with the 
Commonwealth's opportunity to cross-examine the expert; and (2) 
seeking to belittle Friedmann's testimony would reflect poorly 
on the defendant.  At the motion hearing, Pitel, chair of the 
department of pediatrics at Nemours Children's Clinic in 
Jacksonville, Florida, testified that he has treated children 
with lymphoblastic lymphoma since 1978. 
 
Consistent with his affidavit,32 Pitel testified at the 
motion hearing that the professional literature makes clear that 
                     
 
32 Pitel stated in his affidavit: 
 
 
"[I]t is unfortunately not rare to care for children 
whose parents do not fully comply with the demands of 
extended chemotherapy protocols.  Many of these parents 
find the regimen too difficult and burdensome to follow, 
and some cannot understand the risks associated with a 
failure to do so.  This occurs despite all efforts by 
hospital and clinic staff to educate, urge compliance, and 
warn of the risks of noncompliance. . . .  Over the years, 
I have helped care for a significant number of patients 
whose parents were less than compliant.  More than a few of 
28 
 
the adherence rates33 for many long-term drug therapies are no 
more than forty or fifty per cent.  Noncompliance with cancer 
treatment protocols is lowest when the patient is an adolescent, 
but a major concern with pediatric populations generally; 
adherence is a considerable issue with drugs that are used to 
treat an asymptomatic illness or to prevent illness.  Based on 
his experience, Pitel offered several reasons parents do not 
adhere to the treatment protocol:  the immediate side effects of 
the medications are much more obvious than any benefits; 
noncompliance often has no visible detrimental effect, and thus 
parents do not fully appreciate the consequences; when the child 
appears healthy parents often stop complying, especially when 
the child resists the medications; and parents may not believe 
the treatment will work and do what they think will work.  Pitel 
opined that, in this case, the defendant's personal 
circumstances signaled a higher risk of noncompliance, and the 
defendant likely did not understand that her lapses in 
compliance could be lethal, especially given that, according to 
his medical records, Peter achieved remission early on and his 
doctor ordered repeated holds on chemotherapy and told the 
defendant that Peter was doing well throughout the treatment. 
                                                                  
these parents were personally limited and/or had children 
with complex disabilities and/or emotional disorders." 
 
 
33 The degree of adherence varies and may include partial 
adherence or erratic adherence. 
29 
 
 
In denying the defendant's motion for a new trial, the 
judge concluded that defense counsel "chose the best possible 
defense and presented it well at trial."  The judge dismissed 
the importance of Pitel's testimony, reasoning that Pitel agreed 
with Friedmann's treatment plan and Friedman's stated opinion 
that compliance is critically important.  The judge noted that 
Pitel would be unable to opine about the defendant's own intent 
or state of mind.  Although recognizing that the literature 
exploring reasons for noncompliance with similar chemotherapy 
protocols could have been instructive to trial counsel, the 
judge concluded that such "general education would not have 
accomplished 'something material to the defense.'" 
 
b.  Standard of review.  When evaluating an ineffective 
assistance of counsel claim, we consider "whether there has been 
serious incompetency, inefficiency, or inattention of counsel -- 
behavior of counsel falling measurably below that which might be 
expected from an ordinary fallible lawyer -- and, if that is 
found, then, typically, whether it has likely deprived the 
defendant of an otherwise available, substantial ground of 
defence."  Saferian, 366 Mass. at 96.  "In cases where tactical 
or strategic decisions of the defendant's counsel are at issue, 
we conduct our review with some deference to avoid 
characterizing as unreasonable a defense that was merely 
unsuccessful" and ask whether the decision was manifestly 
unreasonable when made (citation omitted).  Commonwealth v. 
30 
 
Kolenovic, 471 Mass. 664, 673-674 (2015).  Strategic choices 
made before a complete investigation are reasonable "[only] to 
the extent that reasonable professional judgments support the 
limitation on investigation" (citation omitted).  Commonwealth 
v. Lang, 473 Mass. 1, 14 (2015).  With respect to our review of 
the denial of a motion for a new trial, we recognize that the 
decision to allow or deny such a motion rests within the sound 
discretion of the motion judge, and we give deference to the 
factual findings of that judge, particularly when he or she was 
also the trial judge.  See Commonwealth v. Pillai, 445 Mass. 
175, 185 (2005). 
 
c.  Discussion.  Trial counsel's decision not to consult 
with an independent oncologist appears to have been a strategic 
decision.  However, given the salient and essentially undisputed 
facts about Peter's life-threatening cancer, his excellent 
prognosis with continued treatment, and the defendant's failure 
to give the prescribed medications over a long period of time, 
it was clear that the defendant's intent would be the key issue 
at trial.  The Commonwealth's theory was that, unlike other 
parents, the defendant failed to administer life-saving 
medications to her son, and she lied about her noncompliance; 
the only explanation for this behavior was that she intended to 
kill her son.  In the circumstances, it was patently 
unreasonable for the defendant's counsel not to consult with a 
qualified pediatric oncologist to explore the disease, its 
31 
 
treatment, and in particular whether experience dealing with 
other caretaking parents might help to identify explanations 
other than an intent to kill the child for a parent's decision 
not to give medications.  See Commonwealth v. Haggerty, 400 
Mass. 437, 442-443 (1987). 
 
The information provided by Pitel in his affidavit and his 
testimony at the motion hearing concerning the noncompliant 
behavior of parents with children suffering from cancer show 
that parental noncompliance is not uncommon.  Many parents do 
not adhere to the treatment protocol for a number of reasons 
other than an intent to kill the patient, including a patient's 
healthy appearance during remission, a parent not wanting to 
make the child sicker, and the absence of apparent adverse 
effects resulting from noncompliance.  Such evidence would have 
been significant in the defendant's case, offering an 
explanation for the defendant's conduct that placed her squarely 
within a group of parents of children similarly situated with 
Peter, and thereby offering an explanation for her conduct that 
was understandable and within some available norm of parental 
behavior -- and not, as the Commonwealth argued, the actions of 
a woman who "seethed" with anger at her former husband and 
intending to kill her son as an act of retaliation against the 
father.  As such, this evidence had the potential of raising a 
reasonable doubt about the existence of the defendant's criminal 
32 
 
intent.34,35  See Commonwealth v. Martin, 427 Mass. 816, 822 
(1998) (affirming allowance of motion for new trial on grounds 
of ineffective assistance where defendant's trial counsel failed 
to call expert to challenge Commonwealth's vulnerable cause-of-
death theory; new evidence on cause of death "could have raised 
a reasonable doubt in the minds of the jury").  See also 
Commonwealth v. Roberio, 428 Mass. 278, 281-282 (1998), S.C., 
440 Mass. 245 (2003) (defendant's trial counsel's failure to 
investigate defendant's lack of criminal responsibility and call 
expert witness constituted ineffective assistance of counsel; 
defendant's motion for new trial should have been allowed).  And 
quite apart from testifying at trial, an expert such as Pitel 
could have educated and informed the defendant's counsel about 
                     
 
34 Although a pediatric oncologist could not have testified 
on direct examination about the substance of the literature 
supporting the opinions he or she had derived from personal 
experience with children and their parents, see Department of 
Youth Servs. v. A Juvenile, 398 Mass. 516, 532 (1986), the issue 
of literature might well have been raised on cross-examination, 
and then available for defense counsel to explore further on 
redirect examination; the issue might have been raised as well 
if the prosecutor challenged the credibility of the witness's 
opinion. 
 
 
35 There was no "inhibiting conflict" between Pitel's 
testimony and the theory of the defendant's defense.  See 
Commonwealth v. Martin, 427 Mass. 816, 822 (1998).  The defense 
sought to portray the defendant as an overwhelmed single mother, 
overburdened by the circumstances, who did not want to make her 
son even sicker.  Peter went into remission early on in 
treatment, and the lapses in medications appeared to make no 
difference in his health.  Pitel's testimony at the motion 
hearing supported the defendant's proffered explanation at trial 
of her motivation and conduct. 
33 
 
the disease, the treatments, and what the medical literature 
teaches concerning treatment compliance by parents -- 
information that would have greatly aided defense counsel in his 
cross-examination of Friedmann and other medical personnel from 
the hospital. 
 
In rejecting the potential value and significance of 
Pitel's testimony, the judge focused particularly on the fact 
that Pitel agreed with Friedmann's treatment protocol,36 that 
Pitel could not testify to the defendant's own state of mind, 
and that the defendant repeatedly had lied.  These reasons are 
not persuasive.  With respect to the lying, Pitel's motion 
testimony suggests he would have been able to offer noncriminal 
reasons why a person in the defendant's circumstances might lie 
about withholding medications.  And although Pitel certainly 
could not testify about the defendant's own state of mind, he 
could explain, based on his own professional knowledge and 
experience, the common patterns of behavior of parents who fail 
to comply in cancer treatment and whether the defendant's 
reported behavior was consistent with those patterns.  See, 
e.g., Commonwealth v. Dockham, 405 Mass. 618, 628 (1989) (expert 
testimony concerning general patterns of behavior of sexually 
abused children).  See also Commonwealth v. Pike, 431 Mass. 212, 
221-222 (2000) (expert testimony on battered woman syndrome). 
                     
 
36 The fact that Pitel agreed with Friedmann's treatment 
protocol is irrelevant to the introduction of evidence regarding 
the treatment compliance of parents. 
34 
 
 
In sum, we conclude that trial counsel's decision to forgo 
any consultation with an oncologist was manifestly unreasonable, 
and likely deprived the defendant of a substantial ground of 
defense on the central disputed issue in the case, namely, the 
defendant's intent.  To deny her motion for a new trial would be 
unjust.  The defendant is entitled to a new trial on the charge 
of attempted murder.37 
 
Conclusion.  The judgment of conviction on the indictment 
charging a violation of G. L. c. 265, § 13L, is affirmed.  The 
judgments of conviction on the indictments charging violations 
of G. L. c. 265, § 13J (b), and G. L. c. 265, § 13K (e), are 
vacated, and judgment is to enter for the defendant on each 
indictment.  The order denying the defendant's motion for a new 
trial on the indictment charging a violation of G. L. c. 265, 
§ 16, is vacated.  The case is remanded to the Superior Court 
for further proceedings consistent with this opinion. 
 
 
 
 
 
 
 
So ordered. 
                     
 
37 In light of our conclusion, we comment briefly on the 
defendant's remaining two claims of ineffective assistance.  
With respect to the ineffectiveness claim concerning Krell's 
records, in light of Commonwealth v. Hanright, 465 Mass. 639, 
644 (2013), the disclosure of Krell's records to the 
Commonwealth's expert does not appear to have been 
inappropriate.  As for the ineffectiveness claim relating to the 
defendant's history with the Department of Children and 
Families, trial counsel's strategic decision to forgo evidence 
of that history was not manifestly unreasonable.