Opinion ID: 867984
Heading Depth: 1
Heading Rank: 2

Heading: evidence of uncharged deaths

Text: Robert’s second argument on appeal is that the district court erred by allowing the government to admit evidence of uncharged patient deaths, 7 Case: 11-15268 Date Filed: 05/15/2013 Page: 8 of 19 specifically death certificates for patients Lewis Hassell and Keaan Amaker, a letter from a medical examiner regarding patient Sara McCormick, and related testimony from family members and experts. Some of the charged unlawful dispersal counts related to Robert’s prescriptions for Hassell, Amaker, and McCormick.3 Robert objected to the admission of any evidence of uncharged deaths in a Motion in Limine prior to trial, and also during the trial. The district court overruled each of these objections, but constrained the jury’s reliance on this evidence through several limiting instructions. Robert argues that the admission of the death certificates and medical examiner letter violated his constitutional rights under the Confrontation Clause. He also asserts violations of the Rules of Evidence. He says the uncharged deaths were irrelevant under Federal Rule of Evidence 401, unduly prejudicial under Federal Rule of Evidence 403, and improper propensity evidence under Federal Rule of Evidence 404(b).
Under the Confrontation Clause, the government “may not introduce ‘testimonial’ hearsay against a criminal defendant, regardless of whether such statements are deemed reliable, unless the defendant has an opportunity to crossexamine the declarant, or unless the declarant is unavailable and the defendant had 3 The government also introduced, as 404(b) evidence, evidence regarding the death of one patient—Ms. Frady—who was not part of any charge in the indictment. Mr. Bourlier does not appear to challenge the introduction of this evidence. 8 Case: 11-15268 Date Filed: 05/15/2013 Page: 9 of 19 prior opportunity for cross-examination.” Ignasiak, 667 F.3d at 1230 (citing Crawford v. Washington, 541 U.S. 36, 53–54, 68, 124 S. Ct. 1354, 1365–66, 1374 (2004)). Generally, we review constitutional claims de novo. United States v. Williams, 527 F.3d 1235, 1239 (11th Cir. 2008). However, if a defendant did not “lodge a timely Confrontation Clause objection” we review only for plain error. United States v. Arbolaez, 450 F.3d 1283, 1291 (11th Cir. 2006). “[A]n objection properly characterized as . . . an evidentiary objection . . . does not constitute a constitutional objection for purposes of appellate review.” United States v. Baker, 432 F.3d 1189, 1206 n.12 (11th Cir. 2005). Thus, for example, “[a] hearsay objection to testimony at trial, standing alone, does not preserve a constitutional challenge under the Confrontation Clause for appeal.” Arbolaez, 450 F.3d at 1291 n.8.
At the point during the trial that Lewis Hassell’s and Keaan Amaker’s death certificates were admitted into evidence, Robert made no Confrontation Clause objection on the record. The Motion in Limine Robert filed before trial did argue that evidence of uncharged deaths should be excluded, but based the argument solely on the Rules of Evidence, as opposed to asserting a constitutional claim. Similarly, no mention was made of the Confrontation Clause when this evidence 9 Case: 11-15268 Date Filed: 05/15/2013 Page: 10 of 19 was discussed during a bench conference before the death certificates were admitted. Then, no new objections were made when the death certificates were actually admitted into evidence. Indeed, the only place in the record Robert points to as raising a Confrontation Clause issue was after the death certificates had already been admitted. Therefore, Robert did not “lodge a timely Confrontation Clause objection” to the admission of the death certificates and we can only review for plain error. See Arbolaez, 450 F.3d at 1291. To prevail under plain error review, Robert must show “(1) error, (2) that is plain, and (3) that affects substantial rights.” United States v. Rodriguez, 398 F.3d 1291, 1298 (11th Cir. 2005) (quotation marks omitted). “If all three conditions are met, an appellate court may then exercise its discretion to notice a forfeited error, but only if (4) the error seriously affects the fairness, integrity, or public reputation of judicial proceedings.” Id. (quotation marks omitted). Even if we assume that Robert satisfies the first two requirements of the plain error test, he has not shown that the admission of the death certificates “affect[ed] his substantial rights.” See id. To satisfy this requirement, Robert must show “a reasonable probability that the result would have been different but for the error” or a “probability sufficient to undermine confidence in the outcome.” Id. at 1299, 1301 (quotation marks omitted). Robert has failed in this regard, because even independent of the challenged testimony there was “overwhelming evidence” 10 Case: 11-15268 Date Filed: 05/15/2013 Page: 11 of 19 in support of Robert’s convictions. See United States v. Turner, 474 F.3d 1265, 1278 (11th Cir. 2007). We note that there was otherwise admissible evidence in the record to show that Lewis Hassell and Keaan Amaker died during the time they were Robert’s patients; the death certificates showed, and it is not disputed, that both Hassell’s and Amaker’s deaths were not caused entirely by drugs Robert prescribed; and after these certificates were admitted, the district court gave a limiting instruction to the jury, approved by Robert’s counsel, explaining that “there [was] no basis upon which [the jury] could find in this case Dr. Bourlier guilty of anything in connection with their deaths.”
In contrast to the death certificates, the Sarah McCormick medical examiner letter was admitted after Robert objected to this type of evidence on the grounds that he could not “cross-examine it.” Assuming that this was sufficient to preserve the Confrontation Clause claim, and reviewing the issue de novo, we conclude there was no violation of the Confrontation Clause. The Confrontation Clause applies to “testimonial statements.” Davis v. Washington, 547 U.S. 813, 821, 126 S. Ct. 2266, 2273 (2006). We have explained that a statement is testimonial if, for example, considering the statement’s “primary purpose” it was “made under circumstances which would lead an objective witness reasonably to believe that the statement would be available for use at a later trial.” 11 Case: 11-15268 Date Filed: 05/15/2013 Page: 12 of 19 United States v. Caraballo, 595 F.3d 1214, 1228–29 (11th Cir. 2010) (quotation marks omitted). Indeed, in every “post-Crawford case in which the [Supreme] Court has found a violation of the confrontation right, the statement at issue had the primary purpose of accusing a targeted individual.” Williams v. Illinois, ___ U.S. ___, ___, 132 S. Ct. 2221, 2243 (2012). The letter at issue here was from the medical examiner’s office and was sent to Robert to request that he provide the examiner with Sara McCormick’s medical records as part of the examiner’s investigation into her death. It was simply a request for a patient’s records without any accusations. Because the letter was not “made under circumstances which would lead an objective witness reasonably to believe that [it] would be available for use at a later trial,” Caraballo, 595 F.3d at 1228 (quotation marks omitted), and it did not have “the primary purpose of accusing a targeted individual,” Williams, 132 S. Ct. at 2243, we find that it was not testimonial. Thus, the admission of the letter did not violate the Confrontation Clause.
Robert challenges the admission of all evidence related to the uncharged deaths, including the death certificates and family members’ testimony, stating that it was irrelevant under Rule 401; that the “probative value [was] substantially outweighed by . . . unfair prejudice” under Rule 403; and that it was improper 12 Case: 11-15268 Date Filed: 05/15/2013 Page: 13 of 19 propensity evidence under Rule 404(b). We review evidentiary rulings for a clear abuse of discretion. United States v. Merrill, 513 F.3d 1293, 1301 (11th Cir. 2008). First addressing Robert’s Rule 404(b) argument, we note that “[e]vidence of a crime, wrong, or other act is not admissible to prove a person’s character in order to show that on a particular occasion the person acted in accordance with the character.” Fed. R. Evid. 404(b). At the same time, evidence of activity is “not extrinsic under Rule 404(b) if it is . . . necessary to complete the story of the crime, or . . . inextricably intertwined with the evidence regarding the charged offense.” United States v. Ramsdale, 61 F.3d 825, 829 (11th Cir. 1995) (quotation marks omitted). The district court did not abuse its discretion by determining that the evidence of the uncharged deaths was not 404(b) evidence because it was “inextricably intertwined with the offenses charged.” Again, the evidence of death was admitted about patients whose care was the subject of the unlawful prescribing counts. These patients were receiving controlled substance prescriptions from Robert and died during the time period alleged in these counts of the indictment. We next consider Robert’s arguments that Rules 401and 402 were violated. Rules 401 and 402 provide that only relevant evidence, defined as evidence that “has any tendency to make a fact [of consequence to the action] more or less 13 Case: 11-15268 Date Filed: 05/15/2013 Page: 14 of 19 probable,” is admissible. Fed. R. Evid. 401–02. These rules reflect a general policy of “liberal admission of evidence.” Allison v. McGhan Med. Corp., 184 F.3d 1300, 1310 (11th Cir. 1999). The district court did not abuse its discretion by finding this evidence to be relevant. For example, evidence that Hassell, Amaker, and McCormick had died, foreclosed any idea that the patients stopped receiving prescriptions from Robert because Robert had stopped treating them. Similarly, evidence of these patients’ deaths would have put to rest any idea that they were not called by the government to testify at trial because they only had good things to say about Robert. Finally, the evidence of these patients’ deaths could be considered by the jury when determining whether Robert knew that his patients were misusing his prescriptions. As we have said, this is one factor that may suggest that Robert distributed controlled substances without a legitimate medical purpose and outside the usual course of professional practice. See Joseph 709 F.3d at 1104. Finally, we consider Robert’s argument that the probative value of this evidence was “substantially outweighed by . . . unfair prejudice” in violation of Rule 403. Fed. R. Evid. 403. Rule 403 is an “extraordinary remedy.” Merrill, 513 F.3d at 1301 (quotation marks omitted). When reviewing a district court’s Rule 403 determination “we look at the evidence in the light most favorable to its 14 Case: 11-15268 Date Filed: 05/15/2013 Page: 15 of 19 admission, maximizing its probative value and minimizing its undue prejudicial impact.” Id. (quotation marks omitted). The district court did not abuse its discretion by finding that any unfair prejudice did not substantially outweigh the probative value of this evidence. See id. We recognize that the evidence of these patient deaths was highly probative. At the same time, we acknowledge that it was prejudicial as well. Our concerns about the prejudice are mitigated, however, by the three jury instructions the district court gave to the jury, see United States v. Mateos, 623 F.3d 1350, 1365 (11th Cir. 2010), as well as the undisputed testimony that other factors besides the drugs prescribed by Robert contributed to each death. Even if we were to accept that the district court did abuse its discretion by admitting this evidence, we can say with “fair assurance, after pondering all that happened without stripping the erroneous action from the whole, that the judgment was not substantially swayed by the error” and that the error was therefore harmless. United States v. Gamory, 635 F.3d 480, 492 (11th Cir. 2011) (quotation marks omitted).