Opinion ID: 3066178
Heading Depth: 3
Heading Rank: 1

Heading: Medical Evidence Concerning Scopazzi’s Death

Text: Appellants contend that the district court denied them a complete defense by improperly excluding evidence that gross medical negligence and Scopazzi’s removal of his breathing tube contributed to Scopazzi’s death. Appellants maintain that the excluded medical evidence was relevant to Appellants’ defense that the stab wounds were not the proximate cause of Scopazzi’s death and that they lacked the requisite intent to kill Scopazzi. The resolution of Appellants’ evidentiary challenge is largely controlled by our decision in Pineda-Doval. In that case, Pineda-Doval challenged his convictions for “ten counts of transportation of illegal aliens resulting in death.” PinedaDoval, 614 F.3d at 1022. He maintained that “the jury should have been instructed that it could find the defendant guilty only if his conduct was the proximate cause of the ten charged deaths. . . .” Id. Pineda-Doval argued that the proximate cause of the aliens’ death was the negligent deployment by Border Patrol agents of a spike strip that caused the defendant’s vehicle to flip over. See id. at 1024. Prior to trial, the district court granted the government’s UNITED STATES V. RODRIGUEZ 19 motion in limine to exclude as irrelevant evidence that the Border Patrol agents had failed to comply with the requisite procedures for deployment of the spike strip. See id. Pineda-Doval argued that the district court failed to properly instruct the jury that the “resulting in death” element required proof that his acts were the proximate cause of the aliens’ deaths. Id. at 1025. We observed that “[a] basic tenet of criminal law is that, when a criminal statute requires that the defendant’s conduct has resulted in an injury, the government must prove that the defendant’s conduct was the legal or proximate cause of the resulting injury. . . .” Id. at 1026 (citation and internal quotation marks omitted). We explained that proof of proximate cause required a showing by the government that the harm suffered by the victim was a foreseeable outcome of the defendant’s conduct. See id. at 1028. The proximate cause showing is more easily met when the intervening event is “not a coincidence or unrelated to the defendant’s prior conduct, but rather was a response to that conduct.” Id. When the intervening event is a response to the defendant’s conduct, “the question is whether the intervening act was abnormal—that is, whether, looking at the matter with hindsight, it seems extraordinary. . . .” Id. (citation omitted). We held: Pineda-Doval’s failed attempt to swerve around the spike strip was the proximate cause of the deaths of ten individuals. It was entirely foreseeable that the Border Patrol would deploy a [spike strip] against the defendant’s Suburban and that Pineda-Doval’s dangerous driving would end in an accident. . . . No reasonable jury could have 20 UNITED STATES V. RODRIGUEZ found that a car accident was an extraordinary result. Id. at 1029. We rejected the defendant’s argument that the Border Patrol agents’ negligence “constituted a superseding cause of the accident. . . .” Id. at 1029. We opined: If we assume that [the Border Patrol agent] made a mistake by pulling the [spike strip] across the road several seconds too early, this mistake was not so extraordinary as to break the chain of causation. Pineda-Doval created the dangerous conditions . . . and, because he refused to pull over in response to [the Border Patrol agent’s] lights and sirens, forced the Border Patrol to use drastic measures to stop him. The resulting deaths of his ten passengers were tragic, but not unexpected. . . . Id. at 1029–30. We held that any error in the district court’s exclusion of evidence that the Border Patrol agents were negligent in failing to follow the requisite procedures for deployment of the spike strip was harmless. “[O]ccasional negligence that should have been anticipated by the defendant does not defeat proximate cause. . . .” Id. at 1029 (citation and internal quotation marks omitted). “To show that the actions of [the Border Patrol agent] constituted a superseding cause that broke the chain of causation between Pineda-Doval’s dangerous driving, that negligence would have had to be so UNITED STATES V. RODRIGUEZ 21 extraordinary that it would be unfair to hold the defendant responsible for the resulting accident and deaths.” Id. at 1034 (citation and internal quotation marks omitted). “Even assuming that the defendant persuaded the jury that timing was essential to the correct and safe deployment of [the spike strip] and that [the Border Patrol agent] made the mistake of pulling the spike strip across the road several seconds too early, no reasonable jury could have found that [the Border Patrol agent’s] actions were extraordinary and could not have been foreseen by [the defendant].” Id. (citations and footnote reference omitted). Therefore,“[t]he district court’s error in excluding evidence of [the Border Patrol] policies on spike strips was harmless beyond a reasonable doubt.” Id. Similarly, in this case we conclude that any error in the district court’s exclusion of evidence concerning medical negligence or Scopazzi’s removal of his breathing tube was harmless beyond a reasonable doubt. Because medical treatment was a foreseeable response to Appellants’ conduct of stabbing Scopazzi, proximate cause was established by the government. See id. at 1028. Appellants failed to proffer evidence establishing medical negligence as a superseding cause of Scopazzi’s death. To make the required showing, Appellants would have to demonstrate that medical negligence and Scopazzi’s removal of his breathing tube were “so extraordinary that it would be unfair to hold [Appellants] responsible for the resulting . . . death[ ].” Pineda-Doval, 614 F.3d at 1034 (citation and internal quotation marks omitted); see also Mitchell v. Prunty, 107 F.3d 1337, 1341 n.8 (9th Cir. 1997), as amended, overruled on other grounds by Santamaria v. Horsley, 133 F.3d 1242, 1248 (9th Cir. 1998) (observing that “if gross maltreatment of the wound was the sole cause of death, the person inflicting the wound will not be liable, because the wound was not the proximate 22 UNITED STATES V. RODRIGUEZ cause of death. In this case, gross maltreatment would have been required to render [the victim’s] gunshot wounds fatal.”) (citation and internal quotation marks omitted). As it was foreseeable in Pineda-Doval that Border Patrol agents would deploy a spike strip to stop a fleeing suspect, it was similarly foreseeable in this case that a victim of multiple deep stab wounds would receive medical care. See PinedaDoval, 614 F.3d at 1034. And, as we held in Pineda-Doval, any negligence in the foreseeable response to the stab wounds does not break the causation chain. See id. The same is true regarding Scopazzi’s removal of his breathing tube. See Sedation and Delirium in the Intensive Care Unit, 14 New England J. of Med. 444 (Jan. 30, 2014) (discussing the accidental removal of endotracheal tube due to delirium and agitation); see also Peter Pressman, M.D., Delirium: An Acute Confusional State, April 23, 2014 (observing that “[a]cute confusional state, also known as delirium or encephalopathy, is so common in hospitals that it’s almost seen as routine by many hospital staff. Between 14 to 56% of all hospitalized patients develop confusion. Intubated patients in the intensive care unit have an even higher rate, reaching about 82%. . . . Such agitated patients may also try to remove tubes or IV lines that are providing life-saving medications.”) (available at http://neurology.about.com/od/Delirium/a/ Delirium.htm)(last visited May 8, 2014). Dr. Morgan’s proffered testimony did not address whether medical negligence was the sole cause of Scopazzi’s death or even an intervening cause. Although Dr. Morgan purportedly opined that “the medical attention [Scopazzi] did receive fell well below well-recognized standards of care resulting in [Scopazzi’s] death,” Dr. Morgan did not state that extraordinary medical negligence or Scopazzi’s removal of UNITED STATES V. RODRIGUEZ 23 his breathing tube caused Scopazzi’s death independent of the stab wounds themselves. Although the district court ruled that Dr. Morgan could testify “regarding the nature of [Scopazzi’s] wounds and the degree of force used to cause them,” Dr. Morgan never actually testified. Appellants also informed the district court that they did not intend to rely on medical negligence as an affirmative defense. Thus, the district court’s exclusion of Appellants’ proffered evidence had no bearing on the fairness of Appellants’ trial because that evidence did not establish medical negligence or removal of the breathing tube as a superseding cause of Scopazzi’s death. Our conclusion that Appellants failed to proffer admissible evidence that extraordinary medical negligence or Scopazzi’s removal of his breathing tube constituted a supervening cause of Scopazzi’s death is bolstered by the Seventh Circuit’s rationale in Brackett v. Peters, 11 F.3d 78 (7th Cir. 1993). In Brackett, the habeas petitioner was convicted of felony murder based on his rape and assault of an 85-year-old woman. See id. at 79. The victim “was admitted to the hospital with a broken arm, a broken rib, and extensive bruises. During her stay in the hospital, which lasted several weeks, she—described as feisty before the rape and beating—became depressed, resisted efforts to feed her, and became progressively weaker.” Id. (internal quotation marks omitted). After her transfer to a nursing home, she continued to regress, even though her physical injuries were healing. Because of her lack of appetite, her doctor ordered placement of a nasal gastric feeding tube. However, the tube could not be inserted, in part because the victim’s facial injuries made insertion of the tube too painful. See id. Approximately ten days after her admission, the victim died when a large quantity of food became lodged in her trachea, 24 UNITED STATES V. RODRIGUEZ asphyxiating her. See id. The habeas petitioner contended that the negligence of the nurse who was feeding the victim caused her death. See id. at 80. In rejecting the habeas petitioner’s argument and holding that the petitioner’s assault was the proximate cause of the victim’s death, the Seventh Circuit observed that “an act is a cause of an event if two conditions are satisfied: the event would not have occurred without the act; the act made the event more likely.” Id. at 79. The Seventh Circuit opined that the nurse’s purported negligence was nothing more than another cause of the victim’s death. See id. at 80. The Seventh Circuit concluded that “a murderer does not avoid conviction by pointing out that his act was only one of many causes that concurred to bring about his victim’s death.” Id. “It is enough if his act was one of the causes-enough therefore if [the petitioner’s] assault made [the victim’s] death more likely and if, but for the assault, she would not have died as soon as she did. . . .” Id. (citations omitted). “Death was the last link in a continuous series of events that began with the assault. [The victim] died a month later, never having returned home. . . .” Id. The court emphasized that had the victim never been assaulted, it is unlikely that she would have been admitted to the hospital to die one month later. See id. The petitioner also argued that the assault caused the victim to become clinically depressed and suicide-prone. According to the petitioner, the victim committed suicide by refusing to eat, and that suicide was a superseding cause of the victim’s death. See id. at 80–81. The Seventh Circuit rejected this argument, reasoning that “[t]he fact that a psychiatric condition, whether or not by precipitating suicide, is one of the causes of a victim’s death does not excuse his UNITED STATES V. RODRIGUEZ 25 murderer. Otherwise, it would be open season on sufferers from mental illness.” Id. at 81 (citations omitted). The court contrasted a chance occurrence, such as a fire at a nursing home, that would be a superseding cause if death resulted. See id. at 80. Other circuits have also held that defendants are liable for murder notwithstanding additional occurrences. For example, in United States v. Swallow, 109 F.3d 656 (10th Cir. 1997), the Tenth Circuit affirmed the defendant’s murder convictions despite the defendant’s argument that the district court erred in failing to provide a “proposed instruction characteriz[ing] an independent intervening cause as the unforeseeable gross negligence of a third party that relieves the defendant of responsibility for the death of the victim. . . .” Id. at 659 (citations omitted). In rejecting the defendant’s argument that negligence on the part of rescuers contributed to the victims’ deaths, the Tenth Circuit held that “in cases involving death from injuries inflicted in an assault, courts have uniformly held that the person who inflicted the injury will be liable for the death despite the failure of third persons to save the victim.” Id. at 660 (citations and alteration omitted). Similarly, in United States v. Guillette, 547 F.2d 743 (2d Cir. 1976), the Second Circuit held that the defendant was liable for the death of a victim who may have accidently triggered a bomb. See id. at 747–48. “The trial judge instructed the jury that even if [the victim] died accidentally through his own actions, the defendants would nonetheless be guilty of conspiracy with death resulting if [the victim’s] death was induced or brought about by some act of a conspiracy in furtherance of the purposes of a conspiracy.” Id. at 748. The Second Circuit ruled that “[a] fundamental 26 UNITED STATES V. RODRIGUEZ principle of criminal law is that a person is held responsible for all consequences proximately caused by his criminal conduct. The concept of proximate cause incorporates the notion that an accused may be charged with a criminal offense even though his acts were not the immediate cause of the victim’s death or injury.” Id. at 749 (citation omitted). “In many situations giving rise to criminal liability, the death or injury is not directly caused by the acts of the defendant but rather results from intervening forces or events, such as negligent medical treatment, escape attempts, or the negligent or intentional acts of a third party.” Id. “Where such intervening events are foreseeable and naturally result from a perpetrator’s criminal conduct, the law considers the chain of legal causation unbroken and holds the perpetrator criminally responsible for the resulting harm.” Id. (citations omitted); see also United States v. Rodriguez, 279 F.3d 947, 950–51 (11th Cir. 2002) (holding in the sentencing enhancement context that “one may be held criminally liable for a victim’s death even where medical negligence or mistreatment also contributed to the victim’s death”) (citation omitted). State courts have also consistently held that the defendant must demonstrate extraordinary medical negligence as the sole cause of death to break the causation chain. See, e.g., People v. Mars, 985 N.E.2d 570, 575 (Ill. App. Ct. 2012), as modified (“The presumption [of causation] must be rebutted by the defendant’s presentation of contrary evidence that the sole cause of death was the intervening gross negligence of physicians. Unskilled or improper medical treatment that aggravates a victim’s preexisting condition or contributes to the victim’s death is considered reasonably foreseeable and does not constitute an intervening act unless the treatment is so bad that it can be classified as gross negligence or UNITED STATES V. RODRIGUEZ 27 intentional malpractice. . . .”) (citations omitted) (emphasis in the original); State v. Shabazz, 719 A.2d 440, 445 (Conn. 1998) (“The rule . . . that such gross negligence may permit the defendant to escape liability when it was the sole cause of the death, strikes an appropriate balance between the notions of criminal responsibility for one’s conduct, on one hand, and intervening cause, on the other.”) (citation omitted); State v. Kirby, 39 P.3d 1, 12 (Kan. 2002) (“It is clear that the physicians’ actions were not so unusual, abnormal, or extraordinary that they could not have been foreseen. The physicians’ negligence, if any, did not supersede the effect of the wounds inflicted by [the defendant] so as to become the sole legal cause of [the victim’s] death.”); People v. Roberts, 826 P.2d 274, 295 (Cal. 1992) (in bank), as modified (“If a person inflicts a dangerous wound on another, it is ordinarily no defense that inadequate medical treatment contributed to the victim’s death. To be sure, when medical treatment is grossly improper, it may discharge liability for homicide if the maltreatment is the sole cause of death and hence an unforeseeable intervening cause. . . .”) (citations omitted). Given the weight of such consistent federal and state precedent, we conclude that Appellants failed to proffer any probative evidence that extraordinary medical negligence or Scopazzi’s removal of his breathing tube was the sole cause of Scopazzi’s death. Indeed, Scopazzi would not have needed medical care or a breathing tube absent Appellants’ infliction of five stab wounds, including a wound that punctured Scopazzi’s lung. The alleged medical negligence or removal of Scopazzi’s breathing tube may have been “another cause of [Scopazzi’s] death,” but neither was a supervening event exonerating Appellants from the death resulting from their assault. Brackett, 11 F.3d at 80 (citations omitted). It was not sufficient for Appellants to simply 28 UNITED STATES V. RODRIGUEZ proffer some evidence of medical negligence or Scopazzi’s removal of his breathing tube without otherwise satisfying the standard for proximate cause. See Pineda-Doval, 614 F.3d at 1034; see also Guillette, 547 F.2d at 749 (“Where such intervening events are foreseeable and naturally result from a perpetrator’s criminal conduct, the law considers the chain of legal causation unbroken and holds the perpetrator criminally responsible for the resulting harm. This principle applies even where the direct cause of death is a force set in motion by the victim himself. . . .”) (citations omitted).6 United States v. Main, 113 F.3d 1046 (9th Cir. 1997) does not compel a contrary result. In Main, we delineated the applicable standard for proximate cause involving an involuntary manslaughter conviction resulting from the defendant’s reckless driving while intoxicated. See id. at 1047. In reversing the conviction, we held that the district court failed to properly instruct the jury that it must find that the defendant’s acts were the proximate cause of the victim’s death. See id. at 1049–50. We observed that “[a]ll of the authorities agree that to be guilty of involuntary manslaughter 6 Consistent with its prior rulings on the government’s motions in limine, the district court did not abuse its discretion when it denied Appellants’ request to cross-examine Dr. Holt, the medical examiner, regarding his description of “the sequelae of puncture wounds” ultimately leading to Scopazzi’s death. Appellants specifically sought to question Dr. Holt concerning Scopazzi’s removal of his breathing tube, a sudden loss of blood, cardiac arrest, and brain swelling. Dr. Holt’s testimony did not open the door to this additional medical evidence because Dr. Holt acknowledged that the complications “flowed from the fact that [Scopazzi] was stabbed.” In any event, Appellants’ proffer did not satisfy the proximate cause standard of complications “so extraordinary that it would be unfair to hold [Appellants] responsible for the resulting . . . death[ ].” Pineda-Doval, 614 F.3d at 1034 (citation and internal quotation marks omitted); see also Brackett, 11 F.3d at 80. UNITED STATES V. RODRIGUEZ 29 the harmful result must be within the risk foreseeably created by the accused’s conduct; if the physical causation is too remote, the law will not take cognizance of it. . . .” Id. at 1049. We considered the foreseeability determination more difficult when the manslaughter charges stem from excessive speed or drunk driving because many individuals speed and/or drive while impaired without killing anyone. See id. Therefore, the foreseeability determination would require careful examination of the individual “conduct engaged in.” Id. We held that reversal of the conviction was warranted because “[w]hen the jury is not told that it must find that the victim’s death was within the risk created by the defendant’s conduct an element of the crime has been erroneously withdrawn from the jury.” Id. at 1050 (citations omitted).7 In stark contrast to Main, Appellants’ convictions were not premised on the more ambiguous acts of “excessive speed or drunk driving.” Main, 113 F.3d at 1049. Rather, Appellants’ use of deadly weapons to directly inflict serious stab wounds carried the completely foreseeable risk that Scopazzi’s injuries would result in death. Moreover, the district court included the concept of proximate cause in the 7 We offered the following example of a sufficient intervening cause: “Suppose [the victim] had been pinned in the wreck and then eaten by a bear. His death would have been the result of the wreck; but for [the defendant’s] driving, he would not have been killed, yet a jury could find as a fact that the death was not within the risk that [the defendant] had created. In the language of the American Law Institute death from a bear was not within the risk foreseeably created by the reckless driving[.]” Main, 113 F.3d at 1049 (citation omitted). 30 UNITED STATES V. RODRIGUEZ instruction on voluntary manslaughter, and the concept of foreseeability in other instructions.8 Because Appellants failed to demonstrate that any medical negligence or removal of a breathing tube was “so extraordinary that it would be unfair to hold [Appellants] responsible for the resulting . . . death[ ],” Pineda-Doval, 614 F.3d at 1034 (citation and internal quotation marks omitted), and because the jury instructions included the concepts of foreseeability and proximate cause, the district court acted within its discretion when it cabined the medical evidence.