Fourth Court of Appeals San Antonio, Texas MEMORANDUM OPINION
No. 04-24-00293-CR
Miranda CASAREZ, Appellant
v.
The STATE of Texas, Appellee
From the 186th Judicial District Court, Bexar County, Texas Trial Court No. 2022CR4915B Honorable Kristina Escalona, Judge Presiding
Opinion by: Rebeca C. Martinez, Chief Justice
Sitting: Rebeca C. Martinez, Chief Justice Lori I. Valenzuela, Justice Lori Massey Brissette, Justice
Delivered and Filed: June 25, 2025
AFFIRMED
A jury convicted appellant Miranda Casarez on one count of serious bodily injury to a
child, see TEX. PENAL CODE ANN. § 22.04(a)(1), and it assessed punishment at twenty-five years
imprisonment. The trial court signed a final judgment in accordance with the jury’s verdict. In
one issue, Casarez challenges the legal sufficiency of the evidence supporting her conviction. We
affirm. 04-24-00293-CR
I. BACKGROUND
In 2021, Casarez was in a romantic relationship with B.C.S., 1 and she cared for B.C.S.’s 0F
two sons: B.C., who was four years old; and B.C.J., who was nine years old. On August 17, 2021,
Casarez found B.C. unresponsive, and she drove him to the Children’s Hospital of San Antonio
(“CHOSA”). B.C. was pronounced dead in the emergency department, and an autopsy determined
that B.C. “most likely died from starvation.” Casarez was indicted on one count of serious bodily
injury to a child. At trial, the State called B.C.J., Kimberley Molina, M.D., a board-certified
forensic pathologist and the chief medical examiner for Bexar County, and James Lukefahr, M.D.,
a physician board certified in general pediatrics and child abuse pediatrics. Casarez called William
R. Anderson, M.D., a physician board certified in anatomic, clinical, and forensic pathology, and
Daniel Gebhard, M.D., a board-certified pediatrician with a subspeciality in pediatric critical care.
A. B.C.J.
B.C.J. testified that Casarez cared for the children while Father worked during the
weekdays. B.C.J. recalled six areas of concern relating to Casarez’s feeding and mistreating B.C..
First, B.C.J. recalled that “whenever I was living there, [Casarez] would not feed [B.C.].”
B.C.J. elaborated that “at first, she started feeding him because my dad was there. And then later
on to that [sic] point where she started not feeding him. She — we — me and [another child] got
fed, but [B.C.] didn’t. So — so she, like, [did] not fe[e]d him at all.” When B.C.’s father was at
home, Casarez would feed B.C. or B.C.’s father would bring food home. B.C. would try to get
food for himself, but he was “not that great” at it. Casarez locked the refrigerator and cabinets.
The only food that was occasionally left out and unlocked was bread. The trial court admitted
photographs and videos showing locks on the refrigerator and kitchen cabinets. One of the videos
1 We will use initials to protect the identity of minors.
-2- 04-24-00293-CR
shows B.C. trying to open the locked refrigerator. If B.C.J. tried giving B.C. some of his food,
Casarez would throw B.C.J.’s food in the trash.
The remaining five areas of concern related to Casarez mistreating B.C. In the second area,
B.C.J. recalled that Casarez would get mad at B.C. and punish him by spanking him with a belt.
Although Casarez aimed to spank B.C.’s butt, she usually missed and hit his back. Third, Casarez
would also, according to B.C.J., punish B.C. by, on one occasion, forcing his mouth open and
pouring hand sanitizer, and on another occasion, hot sauce into it. B.C. would cry because
Casarez’s prying hurt him. Afterwards, Casarez would scoop a cup of water from the toilet and
give it to B.C. Casarez did this even if the toilet water also contained urine. Fourth, Casarez would
wipe the children’s Crocs with bread and feed B.C. the soiled bread. B.C. “ate it all” because he
was hungry. Fifth, every “once in a while” when Casarez was mad at B.C., she would do a “flip-
flop” on him. B.C.J. described a “flip-flop” as “[Casarez] would grab [B.C.] and throw him up
into the air and make sure he falls down to the ground, and it would — it would hurt [B.C.], and
he would cry.” Sixth, Casarez gave B.C. sleeping pills at night. Casarez told B.C.J. to keep what
she did to B.C. a secret.
B. Dr. Molina – Direct Examination
Dr. Molina’s investigation into B.C.’s death included an autopsy that she performed and a
review of B.C.’s medical records. Dr. Molina’s autopsy report, which the trial court admitted into
evidence, notes that there were four indicators that pointed to starvation as the cause of B.C.’s
death. First, B.C. was markedly underweight and had a “precipitous decrease in body weight two
months prior to death.” Second, B.C. had a clinical history of low total protein and albumin. Dr.
Molina explained that albumin is a protein that the body needs, and it is created from food and
other proteins in the body. Third, B.C. had a “paucity of abdominal adipose tissue.” Fourth, Dr.
-3- 04-24-00293-CR
Molina’s autopsy report notes that her “investigation reveals intentional deprivation of food by
caregiver.” Dr. Molina came to this conclusion after reviewing surveillance video from B.C.’s
home and videos that Casarez made of B.C. pleading for bread.
Dr. Molina considered type–1 diabetes as a possible cause, but no evidence supported that
possibility. Type–1 diabetes causes death through diabetic ketoacidosis. Diabetic ketoacidosis in
turn causes blood sugar levels to rise “very, very high,” and it causes the body to create ketones,
which are acids. Autopsy test results revealed that B.C.’s glucose was normal 2 and that there were 1F
no ketones. Additionally, diabetes causes changes in the kidneys that can be visualized, and B.C.’s
kidneys did not exhibit such changes. Thirdly, type–1 diabetes is caused when a person’s pancreas
lacks islet cells, which make insulin. Dr. Molina examined B.C.’s pancreas cells under a
microscope, and she saw islet cells.
C. Dr. Lukefahr
Dr. Lukefahr concluded, as Dr. Molina did, that B.C. died of starvation. He based his
conclusion on three indicators. First, Dr. Lukefahr observed that for B.C.’s first four years, he was
growing well within the normal range of other male children. Then,
pretty abruptly after [B.C.’s] fourth birthday, his weight started declining. And it declined steadily over the course of about the next ten months. And then in a little before his fifth birthday, all of [a] sudden[,] there was this very, very rapid decline leading to the point where he died.
Second, Dr. Lukefahr noted that starvation causes a “peach fuzz” type of hair to appear on
the body, including the trunk and extremities. This hair is called “lanugo.” A photograph of B.C.’s
backside taken after he passed in the emergency department shows hair growth that, according to
Dr. Lukefahr, is consistent with lanugo. Third, B.C. had very little food content in his intestinal
2 Dr. Molina acknowledged that B.C. had two high glucose results as he received emergency medical care. She attributed these to the stress of the dying process. Such readings are why an autopsy measures glucose levels through vitreous — behind the eye — fluid because it tends to be more accurate.
-4- 04-24-00293-CR
tract. Ordinarily, “just because of meals at regular intervals and so forth, there’s evidence of food
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Fourth Court of Appeals San Antonio, Texas MEMORANDUM OPINION
No. 04-24-00293-CR
Miranda CASAREZ, Appellant
v.
The STATE of Texas, Appellee
From the 186th Judicial District Court, Bexar County, Texas Trial Court No. 2022CR4915B Honorable Kristina Escalona, Judge Presiding
Opinion by: Rebeca C. Martinez, Chief Justice
Sitting: Rebeca C. Martinez, Chief Justice Lori I. Valenzuela, Justice Lori Massey Brissette, Justice
Delivered and Filed: June 25, 2025
AFFIRMED
A jury convicted appellant Miranda Casarez on one count of serious bodily injury to a
child, see TEX. PENAL CODE ANN. § 22.04(a)(1), and it assessed punishment at twenty-five years
imprisonment. The trial court signed a final judgment in accordance with the jury’s verdict. In
one issue, Casarez challenges the legal sufficiency of the evidence supporting her conviction. We
affirm. 04-24-00293-CR
I. BACKGROUND
In 2021, Casarez was in a romantic relationship with B.C.S., 1 and she cared for B.C.S.’s 0F
two sons: B.C., who was four years old; and B.C.J., who was nine years old. On August 17, 2021,
Casarez found B.C. unresponsive, and she drove him to the Children’s Hospital of San Antonio
(“CHOSA”). B.C. was pronounced dead in the emergency department, and an autopsy determined
that B.C. “most likely died from starvation.” Casarez was indicted on one count of serious bodily
injury to a child. At trial, the State called B.C.J., Kimberley Molina, M.D., a board-certified
forensic pathologist and the chief medical examiner for Bexar County, and James Lukefahr, M.D.,
a physician board certified in general pediatrics and child abuse pediatrics. Casarez called William
R. Anderson, M.D., a physician board certified in anatomic, clinical, and forensic pathology, and
Daniel Gebhard, M.D., a board-certified pediatrician with a subspeciality in pediatric critical care.
A. B.C.J.
B.C.J. testified that Casarez cared for the children while Father worked during the
weekdays. B.C.J. recalled six areas of concern relating to Casarez’s feeding and mistreating B.C..
First, B.C.J. recalled that “whenever I was living there, [Casarez] would not feed [B.C.].”
B.C.J. elaborated that “at first, she started feeding him because my dad was there. And then later
on to that [sic] point where she started not feeding him. She — we — me and [another child] got
fed, but [B.C.] didn’t. So — so she, like, [did] not fe[e]d him at all.” When B.C.’s father was at
home, Casarez would feed B.C. or B.C.’s father would bring food home. B.C. would try to get
food for himself, but he was “not that great” at it. Casarez locked the refrigerator and cabinets.
The only food that was occasionally left out and unlocked was bread. The trial court admitted
photographs and videos showing locks on the refrigerator and kitchen cabinets. One of the videos
1 We will use initials to protect the identity of minors.
-2- 04-24-00293-CR
shows B.C. trying to open the locked refrigerator. If B.C.J. tried giving B.C. some of his food,
Casarez would throw B.C.J.’s food in the trash.
The remaining five areas of concern related to Casarez mistreating B.C. In the second area,
B.C.J. recalled that Casarez would get mad at B.C. and punish him by spanking him with a belt.
Although Casarez aimed to spank B.C.’s butt, she usually missed and hit his back. Third, Casarez
would also, according to B.C.J., punish B.C. by, on one occasion, forcing his mouth open and
pouring hand sanitizer, and on another occasion, hot sauce into it. B.C. would cry because
Casarez’s prying hurt him. Afterwards, Casarez would scoop a cup of water from the toilet and
give it to B.C. Casarez did this even if the toilet water also contained urine. Fourth, Casarez would
wipe the children’s Crocs with bread and feed B.C. the soiled bread. B.C. “ate it all” because he
was hungry. Fifth, every “once in a while” when Casarez was mad at B.C., she would do a “flip-
flop” on him. B.C.J. described a “flip-flop” as “[Casarez] would grab [B.C.] and throw him up
into the air and make sure he falls down to the ground, and it would — it would hurt [B.C.], and
he would cry.” Sixth, Casarez gave B.C. sleeping pills at night. Casarez told B.C.J. to keep what
she did to B.C. a secret.
B. Dr. Molina – Direct Examination
Dr. Molina’s investigation into B.C.’s death included an autopsy that she performed and a
review of B.C.’s medical records. Dr. Molina’s autopsy report, which the trial court admitted into
evidence, notes that there were four indicators that pointed to starvation as the cause of B.C.’s
death. First, B.C. was markedly underweight and had a “precipitous decrease in body weight two
months prior to death.” Second, B.C. had a clinical history of low total protein and albumin. Dr.
Molina explained that albumin is a protein that the body needs, and it is created from food and
other proteins in the body. Third, B.C. had a “paucity of abdominal adipose tissue.” Fourth, Dr.
-3- 04-24-00293-CR
Molina’s autopsy report notes that her “investigation reveals intentional deprivation of food by
caregiver.” Dr. Molina came to this conclusion after reviewing surveillance video from B.C.’s
home and videos that Casarez made of B.C. pleading for bread.
Dr. Molina considered type–1 diabetes as a possible cause, but no evidence supported that
possibility. Type–1 diabetes causes death through diabetic ketoacidosis. Diabetic ketoacidosis in
turn causes blood sugar levels to rise “very, very high,” and it causes the body to create ketones,
which are acids. Autopsy test results revealed that B.C.’s glucose was normal 2 and that there were 1F
no ketones. Additionally, diabetes causes changes in the kidneys that can be visualized, and B.C.’s
kidneys did not exhibit such changes. Thirdly, type–1 diabetes is caused when a person’s pancreas
lacks islet cells, which make insulin. Dr. Molina examined B.C.’s pancreas cells under a
microscope, and she saw islet cells.
C. Dr. Lukefahr
Dr. Lukefahr concluded, as Dr. Molina did, that B.C. died of starvation. He based his
conclusion on three indicators. First, Dr. Lukefahr observed that for B.C.’s first four years, he was
growing well within the normal range of other male children. Then,
pretty abruptly after [B.C.’s] fourth birthday, his weight started declining. And it declined steadily over the course of about the next ten months. And then in a little before his fifth birthday, all of [a] sudden[,] there was this very, very rapid decline leading to the point where he died.
Second, Dr. Lukefahr noted that starvation causes a “peach fuzz” type of hair to appear on
the body, including the trunk and extremities. This hair is called “lanugo.” A photograph of B.C.’s
backside taken after he passed in the emergency department shows hair growth that, according to
Dr. Lukefahr, is consistent with lanugo. Third, B.C. had very little food content in his intestinal
2 Dr. Molina acknowledged that B.C. had two high glucose results as he received emergency medical care. She attributed these to the stress of the dying process. Such readings are why an autopsy measures glucose levels through vitreous — behind the eye — fluid because it tends to be more accurate.
-4- 04-24-00293-CR
tract. Ordinarily, “just because of meals at regular intervals and so forth, there’s evidence of food
traversing the intestinal tract kind of all the way along.” However, B.C. “had very little content in
his intestinal tract.”
Dr. Lukefahr excluded two possible causes for B.C.’s weight loss suggested by Casarez.
First, Dr. Gebhard suggested that B.C. may have had an autism-type disorder that caused him to
be a “picky eater.” Dr. Lukefahr testified that he had never seen a “picky eater” starve himself to
death. Dr. Lukefahr also testified that the question of whether B.C. had autism is irrelevant to his
starving to death because there is no correlation between autism and starvation. Second, Dr.
Lukefahr confronted a CHOSA medical record indicating that B.C. had a “finger stick glucose” of
300 when resuscitation efforts were performed on him. He acknowledged that such a figure was
“eye-catching” and that there was a possibility that the figure was consistent with diabetes.
However, Dr. Lukefahr cautioned that, to cause death, such a glucose level would have had to
“been going on for a while.” He elaborated that “[t]he nine months that came before those past
last few days were not diabetes. Something else was going on. And maybe diabetes was the
terminal event.”
D. Dr. Anderson
Dr. Anderson pointed to three factors to dispute the conclusion that B.C. died of starvation.
First, Dr. Anderson noted that “[b]rown fat is a response to long-term deprivation of nutrients in
how the body reacts.” Dr. Anderson emphasized that Dr. Molina’s autopsy report makes no
mention of finding any brown fat. Second and third, Dr. Anderson noted that starvation typically
causes a “fatty liver” and myocyte loss or heart muscle degradation. However, Dr. Molina detailed
that there was “nothing abnormal at all on the liver,” and she similarly made no indication of
myocyte loss. Dr. Anderson determined that B.C. died from a cerebral edema, or brain swelling.
-5- 04-24-00293-CR
E. Dr. Gebhard
Dr. Gebhard echoed Dr. Anderson’s opinion that a lack of “fatty infiltration of the liver”
and myocyte loss pointed against starvation as the cause of death. Dr. Gebhard believed that B.C.
suffered from type–1 diabetes and autism. He explained that, in the months leading up to B.C.’s
death, his symptoms of excessive thirst, regression back to using diapers after being potty-trained,
severe mood disorders, and eating but not gaining weight may be associated with type–1 diabetes.
Regarding autism, Dr. Gebhard testified that children with autism may restrict their diet to only
specific foods that have a texture that they like. Dr. Gebhard reconciled this characteristic with
the evidence that B.C. pleaded for bread. He also reconciled evidence that B.C. picked at his ears
and banged his head against the wall as “self-soothing” behaviors associated with autism. Dr.
Gebhard specifically noted that banging your head releases endorphins that can make you feel
better.
Lastly, Dr. Gebhard did not trust the results from tests done at the CHOSA emergency
department on August 17. He explained that when a patient is in cardiac arrest, it is oftentimes
difficult to insert an IV line through a vein. In such situations, healthcare providers drill into the
patient’s bone marrow to access the vascular system and deliver resuscitation medication and
fluids. This is called an interosseous or “IO.” Saline is used to flush the freshly drilled hole, and
it can “flush out what’s in there[.]” Laboratory tests are conducted on what is “draw[n] back.”
According to Dr. Gebhard, laboratory results from such samples “are notoriously awful.”
F. Dr. Molina – Rebuttal Testimony
After Dr. Anderson and Dr. Gebhard testified, the State re-called Dr. Molina for rebuttal
testimony on three areas. First, Dr. Molina explained that people have two kinds of fat: (1) yellow
fat, which is used to store energy for use later; and (2) brown fat, which is used to keep us warm.
-6- 04-24-00293-CR
A person starving loses both kinds of fat. However, brown fat may appear more apparent in
starvation cases. Second, Dr. Molina testified that a fatty liver is not always present in a starvation
case. Third, Dr. Molina explained that myocyte loss is essentially the body digesting itself for
nourishment. Myocyte loss is typically present with chronic, or long-term, starvation, but it may
not necessarily be present in acute starvation. Dr. Molina concluded by opining that B.C. died of
acute rather than chronic starvation.
II. DISCUSSION
A. Standard of Review
When reviewing the legal sufficiency of the evidence, an appellate court must view the
evidence in the light most favorable to the prosecution and ask whether any rational trier of fact
could have found each element of the offense beyond a reasonable doubt. Carter v. State, 620
S.W.3d 147, 149 (Tex. Crim. App. 2021) (citation omitted). The appellate court must give
deference to “the responsibility of the trier of fact fairly to resolve conflicts in the testimony, to
weigh the evidence, and to draw reasonable inferences from basic facts to ultimate facts.” Id.
(quoting Jackson v. Virginia, 443 U.S. 307, 319 (1979)). Circumstantial evidence and direct
evidence are equally probative, and either one alone can be sufficient to establish guilt. Id. (citing
Hooper v. State, 214 S.W.3d 9, 13 (Tex. Crim. App. 2007). Juries are permitted to draw reasonable
inferences from the evidence presented at trial “as long as each inference is supported by the
evidence presented at trial.” Id. at 150 (quoting Hooper, 214 S.W.3d at 15).
B. Argument & Analysis
In Casarez’s sole issue, she argues that Dr. Molina “had the experience of one prior
starvation case,” and that her conclusion of starvation was “in direct opposition to the opinions of
two highly experienced pediatric-death experts.” Casarez essentially argues that, because of their
-7- 04-24-00293-CR
better credentials, the testimony of Dr. Anderson and Dr. Gebhard outweighs the testimony of Dr.
Molina. However, Casarez directs us to no legal authority supporting her argument. See TEX. R.
APP. P. 38.1(i) (“The brief must contain a clear and concise argument for the contentions made,
with appropriate citations to authorities and to the record.”) (emphasis added).
Liberally construing Casarez’s legal sufficiency challenge in light of the appropriate
standard of review, we must ensure that “each inference is supported by the evidence presented at
trial.” Carter, 620 S.W.3d at 150. Together, Dr. Molina and Dr. Lukefahr informed the jury that
(1) B.C.’s weight dropped “pretty abruptly” after his fourth birthday; (2) the lanugo on B.C., seen
in photographs, is a symptom of starvation; (3) B.C. had a paucity of abdominal adipose tissue;
(4) B.C.’s low levels of total protein and albumin signify malnourishment; and (5) B.C. had very
little food in his intestinal track. Dr. Molina and Dr. Lukefahr also explained why they disagreed
with the alternative causes of B.C.’s death espoused by Dr. Anderson and Dr. Gebhard. This
testimony, coupled with B.C.J.’s recollection that “[Casarez] would not feed [B.C.,]” allowed the
jury to draw a reasonable inference that Casarez starved B.C. See id. While Casarez believes Dr.
Anderson’s and Dr. Gebhard’s opinions that B.C. may have died of type–1 diabetes and/or autism
are more compelling, it was within the jury’s province to resolve conflicting expert testimony. See
id.
We overrule Casarez’s sole issue.
III. CONCLUSION
We affirm the trial court’s judgment.
Rebeca C. Martinez, Chief Justice
DO NOT PUBLISH
-8-