Opinion ID: 3175087
Heading Depth: 3
Heading Rank: 4

Heading: Nurse Practitioner

Text: [¶114] Finally, Mr. Griggs challenges the testimony of a nurse practitioner who examined the children in August 2012, over a year after the abuse. The nurse practitioner testified, over objection, as to what the children told her about the abuse and what TP told her about the children’s reports of abuse. The district court admitted the testimony about the children’s statements under W.R.E. 803(4), the exception to the hearsay rule for statements made for purposes of medical diagnosis or treatment. Rule 803 states: The following are not excluded by the hearsay rule, even though the declarant is available as a witness: .... (4) Statements for Purposes of Medical Diagnosis or Treatment. – Statements made for purposes of medical diagnosis or treatment and 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. [¶115] In Stephens v. State, 774 P.2d 60, 72 (Wyo. 1989), overruled on other grounds in Large v. State, 2008 WY 22, 177 P.3d 807 (Wyo. 2002), we recognized there are two aspects to establishing proper foundation for admission of evidence under the medical exception to the hearsay rule in Rule 803(4):    [F]irst, the declarant’s motive in making the statement must be consistent with the purposes of promoting treatment [or diagnosis]; and second, the content of the statement must be such as is reasonably relied on by a physician in treatment or diagnosis. Id., quoting United States v. Renville, 779 F.2d 430, 436 (8th Cir. 1985). See also Blake v. State, 933 P.2d 474, 477-78 (Wyo. 1997); Betzle v. State, 847 P.2d 1010, 1017-18 (Wyo. 1993). [¶116] We revisited the issue in McLaury v. State, 2013 WY 89, 305 P.3d 1144 (Wyo. 2014) in the context of a Sexual Assault Nurse Examiner’s (SANE nurse) testimony. 37 Acknowledging that a SANE nurse has dual roles of providing medical care and collecting and preserving evidence for criminal prosecution, we stated that we would continue to use our two part test, “while still focusing on the trustworthiness of the statements, which can be established by considering one rationale or to some degree both rationales. Id., ¶ 15, 305 P.3d at 1149. [¶117] The nurse practitioner testified with regard to her examination of CM as follows: A. . . . I went into the examination room and spoke to [CM]. Q. Okay. And again, why is it that you’re . . . trying to get information from [CM]? A. Well, . . . it’s important that I try and figure out what happened, and so really, . . . it’s very important for me to get that information from the child before I do my assessment. Sometimes they tell me things they haven’t told anyone else, and so if there was disclosure of certain things that had gone on, then that’s going to maybe change the way I do my assessment . . . so I always speak to the child. Q. And ultimately, are you doing it for purposes of medical diagnosis and treatment? A. Absolutely. Q. Okay. When you talked to [CM], what did she tell you? .... A. I spoke to [CM] and told her what we do at the Children’s Justice Center, which is to – that my job is to try and make sure that children are healthy and safe, and I said, we see children who sometimes grown ups or big people have done things that make children feel sad or uncomfortable or hurt them in some way, and I asked her if anything had happened like that to her. Q. What is it that she told you? A. She nodded her head and . . . I asked her if she could tell me about that, and she said, Byron did it. I asked [CM] what Byron did. She said, I don’t want to tell because it’s . . . kind of nasty. I reassured her that she could tell me anything that she needed to. .... Q. Okay. You had said that [CM] had talked about it being nasty, you reassured her. Did she tell you something after you reassured her? A. Yes. 38 Q. And what is it that she told you? A. . . . She talked about Mr. Griggs putting his mouth on her genital area and sticking it in her pahookie. Q. Okay. And did you talk to her about her pahookie? A. I did. I asked her if she – if she – if she meant that the pahookie was in the front or the back, and she said the front. Q. . . . Was there . . . something that she pointed at? A. She pointed to her genitals. .... Q. Okay. Did you ask any further questions about that happening? A. Yes. I asked if she ever had any bleeding. She said no. I asked her if she had seen Byron do that to anyone else, and she said, yes, my sister. I asked her if she had ever seen anything come out of Byron’s private part, and she said no. Q. Okay. Did you talk to her about any pain? A. I asked her if it hurt her, and she said yes. Following their discussion, the nurse practitioner examined CM but did not find anything unusual. She stated that her “final assessment was that the history for sexual abuse was positive, the examination was normal, negative, and I think she also had an ear infection on the right.” [¶118] The nurse practitioner also testified about SM’s statements to her. She explained her role to SM as she did with CM and asked SM to tell her if anyone had hurt or touched her in a way that made her uncomfortable. She testified that SM told her that a “guy” named “Byrum” had hurt her front and back “mahookie” and she told him to stop. SM explained that he had touched her mahookie with his private part. She said it hurt a little but denied any bleeding or seeing anything come out of his private part. The nurse then conducted a general physical assessment and an anal-genital exam on SM. She stated that SM had a “stuffy nose” and noted various findings from the anal-genital examination but concluded the examination did not show any abnormalities. [¶119] The nurse practitioner’s testimony about the children’s statements clearly fell within the medical diagnosis exception to the hearsay rule in Rule 803(4). The nurse asked the girls questions about the alleged abusive incidents and, specifically, about whether they were injured and what parts of their bodies were involved in the assault. Both of the girls were told the purpose of the examination was to determine if they had been “hurt,” so their motives in making the statements were certainly consistent with the purposes of promoting treatment or diagnosis of a medical condition. Additionally, the content of the statements were reasonably relied on by a medical provider in the 39 treatment or diagnosis of the children’s medical conditions. Although the statements may have had the incidental effect of developing criminal forensic evidence, as in McLaury, the nurse’s testimony fell within the exception. [¶120] The nurse practitioner’s account of foster mother TP’s statements about the children’s reports is more problematic. She recounted to the jury what TP told her about the children’s reports of abuse. Defense counsel objected to this testimony as double hearsay, but the State explained it was not offering it to prove the truth of the matter asserted but to explain what the nurse did in response to the reports. The district court allowed the testimony for that purpose and instructed the jury it was not admitted to prove the truth of the children’s statements. [¶121] As defense counsel noted at trial, the statements were double hearsay, or hearsay within hearsay. W.R.E. 805 states: “Hearsay included within hearsay is not excluded under the hearsay rule if each part of the combined statements conforms with an exception to the hearsay rule provided in these rules.” In other words for double hearsay to be admissible, each level of hearsay must be admissible. The district court allowed the testimony on the grounds that it was not offered for the truth of the matter asserted but to show how the nurse focused her examination, and specifically instructed the jury as to the limited purpose of the testimony. [¶122] The foster mother’s account of the children’s statements was the first level of hearsay. This situation invokes the same rules and concerns addressed in our discussion of TP’s trial testimony, above. In this instance, the district court properly instructed the jury of the limited purpose of the testimony. However, the nurse testified about the details of the children’s reports to TP, including the number of times the abuse occurred. As we explained, supra, the rule which permits such testimony to be admitted to show its effect on the hearer, i.e., how the nurse focused her examination, only allows admission of the basic facts necessary for that purpose. It does not allow a detailed rendition of the declarants’ statements. The district court, therefore, improperly allowed the nurse to give a detailed account of TP’s report of the children’s statements.