In the Court of Appeals Sixth Appellate District of Texas at Texarkana
No. 06-25-00062-CR
STEPHEN ALAN KING, Appellant
V.
THE STATE OF TEXAS, Appellee
On Appeal from the 271st District Court Wise County, Texas Trial Court No. CR25052
Before Stevens, C.J., van Cleef and Rambin, JJ. Memorandum Opinion by Justice Rambin MEMORANDUM OPINION
A Wise County1 jury convicted Stephen Alan King of the first-degree felony offense of
knowingly causing serious bodily injury by omission to a child, his 28-month-old daughter,
Ava.2 See TEX. PENAL CODE ANN. § 22.04(e) (Supp.). The jury assessed King’s punishment as
twenty years’ imprisonment. The trial court entered judgment on that verdict. In his sole point
of error on appeal, King argues that the evidence is insufficient to support the jury’s verdict
because the evidence fails to establish that he acted knowingly in the commission of this offense.
Because we find that the evidence supports the jury’s verdict, we affirm the trial court’s
judgment.
I. Standard of Review and Applicable Law
“The due process guarantee of the Fourteenth Amendment requires that a conviction be
supported by legally sufficient evidence.” Braughton v. State, 569 S.W.3d 592, 607 (Tex. Crim.
App. 2018) (citing Jackson v. Virginia, 443 U.S. 307, 315–16 (1979)). “We assess legal
sufficiency by viewing the evidence in the light most favorable to the verdict and asking whether
any rational trier of fact could have found the essential elements of the crime beyond a
reasonable doubt.” Bittick v. State, 707 S.W.3d 366, 368 (Tex. Crim. App. 2024) (citing
1 This appeal was transferred to this Court from the Second Court of Appeals pursuant to a Texas Supreme Court docket equalization order. See TEX. GOV’T CODE ANN. § 73.001 (Supp.). Accordingly, we apply the precedent of the Second Court of Appeals in deciding this case to the extent that it conflicts with our own. See TEX. R. APP. P. 41.3.
2 We use pseudonyms to protect the identities of the children. See TEX. CONST. art. I, § 30(a)(1) (conferring crime victims with “the right to be treated with fairness and with respect for the victim’s dignity and privacy throughout the criminal justice process”); TEX. R. APP. P. 9.10(a)(3); McClendon v. State, 643 S.W.2d 936, 936 n.1 (Tex. Crim. App. [Panel Op.] 1982). 2 Jackson, 443 U.S. at 319). “We compare the trial evidence to ‘the elements of the offense as
defined by a hypothetically correct jury charge for the case.’” Id. at 369 (quoting Zuniga v.
State, 551 S.W.3d 729, 733 (Tex. Crim. App. 2018)). A hypothetically correct jury charge
“accurately sets out the law, is authorized by the indictment, does not unnecessarily increase the
State’s burden of proof or unnecessarily restrict the State’s theories of liability and adequately
describes the particular offense for which the defendant was tried.” Johnson v. State, 364
S.W.3d 292, 294 (Tex. Crim. App. 2012) (quoting Malik v. State, 953 S.W.2d 234, 240 (Tex.
Crim. App. 1997)).
“This familiar standard [of review] ‘recognizes the trier of fact’s role as the sole judge of
the weight and credibility of the evidence after drawing reasonable inferences from the
evidence.’” Braughton, 569 S.W.3d at 608 (quoting Adames v. State, 353 S.W.3d 854, 860 (Tex.
Crim. App. 2011)). “On review, this Court determines whether the necessary inferences made
by the trier of fact are reasonable, based upon the cumulative force of the evidence.” Id. (quoting
Adames, 353 S.W.3d at 860). “We presume that the factfinder resolved any conflicting
inferences in favor of the verdict, and we defer to that resolution.” Id. “As a reviewing court,
we may not reevaluate the weight and credibility of the evidence in the record and thereby
substitute our own judgment for that of the factfinder.” Id. “A reviewing court is thus ‘required
to defer to the jury’s credibility and weight determinations.’” Id. (quoting Brooks v. State, 323
S.W.3d 893, 899 (Tex. Crim. App. 2010)). “However, juries are not permitted to come to
conclusions based on ‘mere speculation or factually unsupported inferences or presumptions.’”
Id. (quoting Hooper v. State, 214 S.W.3d 9, 15 (Tex. Crim. App. 2007)).
3 “In reviewing the sufficiency of the evidence, we should look at ‘“events occurring
before, during and after the commission of the offense and may rely on actions of the defendant
which show an understanding and common design to do the prohibited act.”’” Hammack v.
State, 622 S.W.3d 910, 914 (Tex. Crim. App. 2021) (quoting Hooper, 214 S.W.3d at 13). “Each
fact need not point directly and independently to the guilt of a defendant, as long as the
cumulative force of all the incriminating circumstances is sufficient to support the conviction.”
Walker v. State, 594 S.W.3d 330, 335 (Tex. Crim. App. 2020) (citing Hooper, 214 S.W.3d at
13). “Direct evidence and circumstantial evidence are equally probative, and circumstantial
evidence alone may be sufficient to uphold a conviction so long as the cumulative force of all the
incriminating circumstances is sufficient to support the conviction.” Ramsey v. State, 473
S.W.3d 805, 809 (Tex. Crim. App. 2015). Further, we “consider all of the admitted evidence,
regardless of whether it was properly admitted.” Stahmann v. State, 602 S.W.3d 573, 577 (Tex.
Crim. App. 2020) (citing Jackson, 443 U.S. at 319).
Here, King was charged with “knowingly, by omission, caus[ing] serious bodily injury to
[Ava] . . . by failing to provide adequate food and water.” Relevant here, “[a] person commits an
offense if he . . . knowingly, . . . by omission, causes to a child . . . serious bodily injury.” TEX.
PENAL CODE ANN. § 22.04(a)(1) (Supp.). “A person acts knowingly, or with knowledge, with
respect to a result of his conduct when he is aware that his conduct is reasonably certain to cause
the result.” TEX. PENAL CODE ANN. § 6.03(b).
4 II. The Evidence at Trial
Eric Debus, who was the chief of police for the Rhome Police Department, testified that
he was called to the home of a deceased child on April 26, 2023, at approximately 3:11 p.m.
Debus said he arrived at the home and entered the main living area, which had a kitchen to the
left and the master bedroom to the right.
When he entered the home, Debus first found another officer holding Ava’s younger
brother, Dustin. Debus then found medics evaluating Ava in the master bedroom. Debus said,
“[T]here was no bringing the child back,” and he asked the medics to stop their interventions in
order to maintain the integrity of the scene. Debus said that King “was there and [was] very
distraught.”
Debus testified that the home was “[v]ery unkempt” and “not maintained at all,” with
“[d]ebris, toys, things just everywhere.” Debus said, “It was difficult to walk through the house
without stepping on things or without lifting your feet up to keep from kicking things,” but
Debus said there was no odor or indication of drugs in the home. Debus testified that there was a
case of bottled water on the kitchen floor, Whataburger cups sitting next to the bed in the master
bedroom, and a muffin on the bed.
Debus saw a dog chained to a tree to the left of the front door with no water or food. He
fed the dog with dog food from inside the house and said that the dog “responded as if it [had
not] had food or water in a long time,” and “it was very skinny.”
The Texas Rangers were called in to investigate, and Ranger Job Espinoza, one of the
lead investigators, testified at trial. Espinoza arrived at the scene the afternoon of Ava’s death.
5 Espinoza said that King’s home was very dirty, with signs of “overall neglect and dirty diapers
all over the place.” Espinoza testified that the home smelled of rotten food, urine, and feces. He
said that he saw a Whataburger sack, peanut butter, a muffin, and doughnuts in the master
bedroom. Espinoza testified King later told him that King had gotten the muffins for Dustin that
morning. Espinoza also saw feces rubbed on Ava’s crib and on the wall near her crib. Espinoza
testified that King later told him that Ava had reached in her diaper and put feces on the wall and
on her crib.
Espinoza testified that he interviewed King sometime later in the day of Ava’s death
because King was too distraught at the time of her death to answer coherently. Espinoza testified
that when he interviewed King, King said that he put Ava and Dustin to bed at approximately
8:00 p.m. on April 25. Espinoza stated that King told him Ava was fussy, so he got her out of
bed and let the children watch a movie. Espinoza testified that King said he then put the children
back to bed between 11:30 p.m. and midnight. King told Espinoza that Mother came home
around midnight and slept, then awoke to go to work early the next morning. Espinoza testified
that King told him that he checked on the children when Mother left for work, but they appeared
to be sleeping, so he went back to sleep.
When Dustin awoke King at 2:30–2:45 p.m., King retrieved Dustin from his crib in his
bedroom and then went to check on Ava in her crib in her bedroom. Espinoza testified that King
told him he found Ava unresponsive, not breathing, and stiff. Espinoza stated that King told him
he knew Ava was deceased. Espinoza testified that King stated he then took Ava to his
bedroom, placed her on his bed, and called 9-1-1. It was about 3:01 p.m. on April 26, 2023.
6 Espinoza said a fireman at the scene gave Dustin a bottle of formula, but Dustin later
threw up quite a bit. Dustin was evaluated at a hospital that day but was released to Mother and
her mother that night. A more thorough evaluation of Dustin was later requested, and Dustin
was admitted to Cook Children’s Medical Center, where he stayed for about two weeks.
Espinoza said that King, Mother, and Dustin all appeared to be sick on the day of Ava’s
death, as they were coughing, congested, and had runny noses. Espinoza said that Mother was
very skinny and that Ava and Dustin looked malnourished and skinny.
Espinoza’s investigation indicated that Mother did not have any interaction with the
children for a couple of days prior to Ava’s death due to her work schedule. Although she had
returned home around midnight the night before Ava’s death, she got up and left for work early
the next morning without checking on the children.
Espinoza testified that he determined, based on King’s timeline, that Ava had been in her
crib for approximately fifteen hours when King found her. Espinoza said that he was told Ava
could not get out of the crib on her own. King did not give the children formula or food or
change their diapers during the fifteen hours they remained in their cribs.
Dr. Stephen Lenfest, medical examiner at the Dallas County Medical Examiner’s Office
at the Southwestern Institute of Forensic Sciences, testified about the autopsy he performed on
Ava. Lenfest testified that Ava’s eyes were recessed into her eye sockets, a condition usually
seen in someone who is malnourished or dehydrated. There was a degree of temporal wasting,
meaning “the area of the scalp above her ears and on the side of the forehead [were] just thinner
than it ought to be.” The temporal wasting also indicated malnutrition.
7 Lenfest testified that Ava’s diaper was saturated with urine and contained feces. Ava had
diaper rash, which Lenfest testified was indicative of her diapers being left on for too long.
Lenfest described Ava’s buttocks as having “very superficial” ulcerations that were due to
prolonged exposure to fecal material rather than being pressure ulcers caused by being in one
position for too long. Lenfest determined that Ava had lost “skin turgor,” which indicates
dehydration because the skin loses elasticity and will “tent” when pulled up due to a lack of
moisture rather than returning to its normal position.
Lenfest testified that some of Ava’s organs had a moist appearance, as they should, but
others did not glisten as much and instead were sticky or tacky, which indicated dehydration.
Lenfest observed a small amount of fluid in Ava’s lungs and some bronchi, along with
inflammation, which was likely caused by mild bronchitis.
Lenfest said Ava’s toxicology report showed the presence of acetone, which indicated
she was malnourished, as her body was breaking down fat because it did not have enough
carbohydrates and glucose to produce energy. Ava also had elevated levels of sodium, chloride,
creatine, and urea nitrogen, which all indicate kidney dysfunction and hypernatremia
dehydration.3 Lenfest testified that Ava had acute kidney injury. Ava also tested positive for
rhinovirus and enterovirus, which he described as being associated with the common cold and
causing upper respiratory and gastrointestinal symptoms. Lenfest testified that Ava probably had
a mild upper-respiratory infection.
3 Dr. Kristen Reeder, an assistant professor of pediatrics in the Department of Pediatrics at the University of Texas (UT) Southwestern Medical School and a board-certified child-abuse pediatrician at UT Southwestern Children’s Medical Center in Dallas, the State’s second expert, described hypernatremic dehydration as the “loss of water from the body that causes an increase in the concentration of sodium.” 8 Lenfest said Ava had nothing in her stomach and a very small amount of urine in her
bladder. He testified that she had fecal material in her small and large intestines, which indicates
she did have food and nutrition, but he opined that whatever nutrition she had received was not
enough. Lenfest testified that Ava was twenty-one pounds and thirty-four inches in length at the
time of her autopsy, which put her below the third percentile for her weight and between the
fifteenth and twenty-fifth percentile for her height. Lenfest stated that because he did not have
Ava’s baseline information, he did not know whether her growth had been consistent.
Lenfest concluded that Ava’s cause of death was due to “complications of neglect,
including malnutrition and hypernatremic dehydration.” Lenfest noted Ava’s manner of death as
homicide.
Lenfest said that rhinovirus and enterovirus would not be expected to cause death by
themselves, but Ava was already in a fragile condition due to malnutrition and dehydration, so a
common cold was more significant to her health than it would have been to a healthy child.
While Lenfest stated that the complications of neglect, including malnutrition and dehydration,
were the primary causes of Ava’s death, the rhinovirus and enterovirus “probably did contribute”
to her death. When asked whether he could rule out bronchitis, enterovirus, or rhinovirus as
Ava’s cause(s) of death, Lenfest said his opinion and his autopsy report show that he did rule
those contributing factors out. When questioned whether Ava’s illness was clearly sufficient to
cause her death and whether the malnutrition and dehydration were clearly insufficient to do so,
Lenfest responded, “I don’t think so.”
9 Reeder (who, as noted above, is a board-certified child-abuse pediatrician at UT
Southwestern Children’s Medical Center in Dallas) reviewed Ava’s and Dustin’s medical
records at the request of the Department of Family and Protective Services. Reeder testified that
Ava was in the seventh percentile of weight when she was born. At her two-week and two-
month visits, Ava was gaining weight, and there were no concerns. Just after Ava turned four
months old, Mother called Ava’s pediatrician and said that Ava was spitting up half of her
formula. At her six-month visit, Ava’s weight was in the fifteenth percentile. At her nine-month
well-child visit, when Ava was ten months old, King reported that Ava was eating more solid
foods but was only drinking two bottles of formula per day. King was told to increase Ava’s
bottle intake to four bottles per day. At that appointment, Ava had lost weight.
Ava was taken in for a weight check when she was eleven months old. Ava was
reportedly taking three to four bottles per day, and her parents were adding calories to foods to
increase her caloric intake. Ava had gained a small amount of weight. King and Mother were
told to continue fortifying Ava’s formula by mixing higher calorie concentrations.
Although Ava had a twelve-month well-child visit scheduled, she was not seen for six
more months. Ava was seventeen months old at that time. Her pediatrician noted that Ava had a
diaper rash and was thin for her age. The pediatrician recommended giving Ava PediaSure twice
daily in addition to increasing the calories of her food. Although Ava had an eighteen-month
well-child visit scheduled and should have been seen for a twenty-four-month well-child
checkup, she was never seen again by her pediatrician.
10 Reeder’s medical assessment notes that the six-month well-child visit was the last
appointment Mother attended, and after that, King brought Ava in for her visits. Reeder notes
that Ava was seen regularly until her nine-month well-child checkup, “at which point she had
fallen below the growth curve for weight.” At the time of her death, Ava weighed twenty-one
pounds. Reeder stated that Ava should have been twenty-four pounds by then. Reeder based
that opinion on Ava’s previous growth history and where she should have been on her growth
curve.
Reeder testified as to the findings in Lenfest’s autopsy. She concluded that she had no
reason to disagree with Lenfest’s determination of Ava’s cause and manner of death, although,
unlike Lenfest, Reeder believed the skin breakdown on Ava’s buttocks was pressure ulcers,
which occur from sitting in one place or position for a prolonged period.
Reeder testified that a typical twenty-eight-month-old child would act on hunger and
thirst cues to get food and water any way they could. She stated that the history that she was
given of Ava’s last hours and days did “not match[] objectively the information in her autopsy.”
Reeder stated that a child in Ava’s condition, a few days before his or her death, “would not have
been a child that was normal and then died.” In “the hours before her death, [Ava] would have
been very weak, . . . very fussy or irritable.” She would have been hungry, thirsty, not feeling
well, perhaps having seizures, unresponsive, and inactive, and would have acted abnormally.
Reeder testified, “This would not have been a normal child in the last several days of her life.”
Based on her experience and training, Reeder opined that Ava’s appearance would have
prompted a reasonable caregiver to provide Ava with medical treatment, food, and/or water.
11 Reeder testified that if a child is already dehydrated and malnourished, then goes fifteen
hours without food or drink, that could be enough to cause death, especially considering the
child’s size, age, and medical condition. Reeder opined that the direct cause of Ava’s death was
physical neglect—specifically, nutritional neglect, the restriction of food and water, with
evidence of prior medical neglect due to lack of appropriate medical care and follow-up.
Reeder also gave an opinion after reviewing Dustin’s records. According to Reeder,
Dustin had also missed well-child appointments and had issues with weight gain. King and
Mother were instructed to fortify Dustin’s formula, just as with Ava. Two weeks later, at his
two-month well-child checkup, King and Mother said that Dustin was vomiting when they
increased his calories, so they stopped. The two-month well-child visit was the last time Dustin
was seen by his pediatrician.
About a month before Ava’s death, the children’s grandfather took Dustin to the hospital
because he had choked on a muffin. On the date of Ava’s death, Dustin was taken to the
emergency room because of the circumstances surrounding Ava’s death. His weight that day
was the same as it had been a month prior when he was seen in the emergency room. On the
date of Ava’s death, Dustin’s weight placed him in the sixth percentile on weight growth charts.
One year later, after Dustin had been removed from his parents, he was in the seventy-fourth
percentile.
Reeder testified that Dustin’s laboratory work caused concern regarding his electrolyte or
mineral abnormalities, as well as concern for kidney injury due to dehydration and malnutrition.
Reeder testified that Dustin’s laboratory work showed symptoms of Refeeding Syndrome, the
12 necessity of reintroducing calories of food slowly after a period of malnutrition to avoid
“shock[ing] the system” and causing symptoms such as a sudden drop in electrolyte levels, heart
attacks, and other problems. Dustin remained in the hospital until May 8—about two weeks
after Ava’s death.
James Pace, King’s best friend, testified that he visited King’s house three times per week
or more, and if they were not at King’s house, King and his children were at Pace’s house. Pace
testified that King and Mother kept house like he would expect young parents to do.
Pace said that King kept fruits, vegetables, and protein in the home for Ava and Dustin.
Pace said that King kept snacks like Goldfish and Capri Sun juice packs, and food like
Hamburger Helper and fried chicken, also. Pace said King’s children always had a sippy cup of
juice, water, or milk. He further stated that King always had bottled water or tap water available,
and drinks in the refrigerator. Pace said that he never saw King deny his children food or water.
Pace further stated that King would interrupt his conversation to stop and get something for the
children if they needed or wanted something.
Pace testified that Ava was verbal and would ask for things like crackers, juice, milk, or
water. King’s children had stayed at Pace’s house before, and Pace said that Ava and Dustin
never acted as if they were deprived of food or water.
Pace testified that he had previously discussed the children’s weights with his wife and
with King. Pace’s wife, a certified nurse’s aide, commented that Ava and Dustin were both
small and would not gain weight like Pace’s children would. King told Pace he did not
understand why the children were underweight because Ava ate “like a horse,” and King could
13 not keep food out of Dustin’s mouth. Pace expressed surprise that the children were diagnosed
as malnourished because of the number of times he saw them eating and drinking. Pace testified
that he did not believe King did anything wrong in the care of his children.
Pace stated that he was at King’s home the night before Ava’s death, but King’s children
were already asleep. Pace had seen King’s children the night before that, eating dinner and
playing. He said that Ava appeared to be coming down with a cold. Pace said he never had any
concerns that King neglected Ava or Dustin.
Pace was aware that King used cocaine in February 2023, and Pace said that he told King
“he needed to make some adjustments.” Pace was unaware whether King stopped using cocaine
before Ava’s death. Pace testified that King was an “utter wreck” after Ava’s death, and he cried
and prayed a lot and said he did not understand how that could happen
King’s sister, Alice, testified that she often babysat Ava and Dustin several times a week
while King worked. Ava and Alice’s daughter were nine months apart in age. Alice kept the
children each Thursday through Sunday from 1:00 or 2:00 p.m., and King would pick them up
between 2:00 and 3:00 a.m., after getting off work. Other family members would also babysit
Ava and Dustin, including King’s father.
Alice last saw Ava when she babysat King’s children two days before Ava’s death. Ava
was sick at that time, but she did not have symptoms of diarrhea or vomiting at Alice’s home.
Alice relayed that four days before Ava’s death, King was working, and King’s father
was babysitting Ava and Dustin. Alice testified that they had a family gathering during that visit
14 with a lot of food for everyone to eat, including smoked ribs, fruit trays, candy, cupcakes, beans,
potato salad, watermelon, and strawberries.
Ava’s and Dustin’s maternal grandparents did not live in Wise County, and Alice said
King’s children visited them once per month. Alice testified that the children’s maternal
grandmother was a registered nurse, and King and Mother often asked her for advice.
Alice was not concerned about the state of King’s home, considering he had two toddlers.
She stated that most of the clutter was toys, blankets, snacks, and clothes. Alice testified that
there was always food in King’s home. Alice was at King’s home about two weeks prior to
Ava’s death, and she saw food and water in the home. Alice said that King had a snack drawer
in the refrigerator, and Ava could get her own food and drinks out. She said Ava would
communicate when she was hungry or thirsty, and she had never seen anyone deny Ava food or
water.
Alice testified that her youngest daughter and Ava had similar statures and the women in
the King family were all small in size with high metabolisms. Alice testified that her children
are small, but they “eat like crazy.” Alice said that she believed her daughter and Ava weighed
about the same even though her daughter was nine months older and was a little taller than Ava.
Alice testified as to several photographs of Ava and Dustin. One photograph shows Ava
and Dustin with cupcake icing on their faces. Other photographs show Dustin with cake on his
face eating Cheetos and muffins. Those photographs were taken between four and nine days
before Ava’s death.
15 Alice stated that King and Mother started having marital problems in December of 2022
and that things were not getting better or worse from February into April 2023. Alice said that
Mother was “cheating on” King, “staying out all hours of the night,” and using drugs. Alice said
that she did not know about King’s cocaine use in February, March, or April 2023. Alice also
did not know Ava and Dustin were each diagnosed with poor weight gain. Alice stated that King
had a large support system to help him care for Ava and Dustin, and if there had been any
concerns or signs of abuse or neglect, the family would have intervened.
During Espinoza’s testimony, numerous photographs of King’s home were admitted into
evidence. The photographs depict toys, blankets, shoes, and clothes almost completely covering
the floor in the living room and bedrooms. The photographs show food and food trash including
a full Welch’s bottle and several sippy cups on a kitchen counter; an unopened case of bottled
water and an additional, partially used case on the kitchen floor; packaged snacks, ramen
noodles, cereals, instant mashed potatoes, and canned goods on some shelves in the kitchen; a jar
of peanut butter and other packaged snacks on the floor next to the bed in the master bedroom;
an Oreo snack-pack package on the living room floor; innumerable fast-food cups, wrappers,
containers, and bags on the kitchen counter, the kitchen floor, and the floor of the master
bedroom; and a package of muffins, plus a muffin out of the package, on the bed next to Ava’s
body.
The photographs also show at least a half-dozen soiled diapers on a dresser and on the
floor in Dustin’s room; an overflowing diaper disposal container in the master bedroom; and
soiled diapers next to the bed and the bathroom trashcan in the master bedroom. There were
16 photographs of feces on the wall next to and on Ava’s bed. There was a clothes hamper piled
high in the master bedroom and three more hampers full-to-overflowing in the hallway between
Ava’s room and the kitchen, two of which blocked the hallway. A baby gate was erected
between the kitchen and the living room. The refrigerator had no handles on either the
refrigerator or freezer section.
III. Legally Sufficient Evidence Supports King’s Conviction
In his sole point of error, King argues that the evidence at trial was insufficient to
establish that he knowingly intended to cause Ava’s injury through omission or that he
“knowingly withheld food and water knowing that it was reasonably certain to result in serious
bodily injury or in [Ava’s] death.”
In the context of knowingly causing injury to a child by omission, “the State’s burden [is]
to show that Appellant had a statutory duty to act, he failed to act, and in failing to act, he . . .
knew serious bodily injury would be caused, but he still failed to act.” Cockrell v. State, 721
S.W.3d 448, 454 (Tex. Crim. App. 2025) (citing TEX. PENAL CODE ANN. § 22.04). “Stated
another way, ‘knowingly’ causing the child’s injury requires evidence that the defendant was
aware with reasonable certainty that the result of serious bodily injury . . . would have been
prevented had the defendant performed the act that was omitted.” Proo v. State, 587 S.W.3d
789, 810 (Tex. App.—San Antonio 2019, pet. ref’d).
Injury to a child is “a result-oriented offense.” Cockrell, 721 S.W.3d at 454 (quoting
Williams v. State, 235 S.W.3d 742, 750 (Tex. Crim. App. 2007)). “[P]roving a violation of
[Section 22.04(b), then,] requires evidence that the accused possessed a mental state that relates
17 to ‘the result of that conduct[,]’ rather than simply to the conduct itself (or in this case, the lack
of conduct).” Id. (third alteration in original) (quoting Williams, 235 S.W.3d at 750).
The jury charge tracked the language of the indictment and required that the State prove
that King “by omission, knowingly cause[d] serious bodily injury to [Ava], . . . by failing to
provide adequate food or water.”4 The State had to prove, then, that King knew that failing to
provide adequate food and water to Ava would cause her serious bodily injury.
We first note that King’s point of error is framed in terms that would hold the State to a
higher evidentiary burden than was required under the facts presented. Regarding the meaning
of “serious bodily injury,” the jury charge tracked the language of the indictment, and further,
used the statutory definition of “serious bodily injury.”5 Yet, King’s point of error includes
language indicating that the State had to show that he “knowingly withheld food and water
knowing that it was reasonably certain to result in serious bodily injury or in his daughter’s
death,” and much of his argument focuses on an alleged lack of evidence that King knowingly
caused Ava’s death. (Emphasis added). Although “[s]erious bodily injury” includes bodily
injury that causes death, it also includes bodily injury that creates only “a substantial risk of
death” or causes “serious permanent disfigurement, or protracted loss or impairment of the
function of any bodily member or organ.” TEX. PENAL CODE ANN. § 1.07(a)(46).
4 Per Section 22.04(b)(1), the indictment and charge also alleged that King had a statutory duty to act. See TEX. PENAL CODE ANN. § 22.04(b)(1) (Supp.). King does not deny that he had a statutory duty to provide for his daughter. See TEX. FAM. CODE ANN. § 151.001(a)(3) (Supp.). 5 The jury charge defined “serious bodily injury” as Section 1.07(a)(46) of the Texas Penal Code does. See TEX. PENAL CODE ANN. § 1.07(a)(46) (Supp.). King has not raised any charge error on appeal. 18 This differentiation is important because King argues that Lenfest’s testimony—
specifically, his response of “I don’t think so” when questioned whether Ava’s illness was
clearly sufficient to cause her death and whether the malnutrition and dehydration were clearly
insufficient to do so—was insufficient to support the jury’s verdict. In this limited portion of
Lenfest’s testimony, he was questioned as to whether the results of King’s actions were
sufficient to cause Ava’s death—he was not questioned about whether King’s actions were
sufficient to cause Ava’s serious bodily injury. Because the indictment and the jury charge
charged King with causing serious bodily injury, not death, his arguments that the evidence was
insufficient to show that he knowingly caused Ava’s death, and specifically his arguments
regarding the excerpt from Lenfest’s testimony, miss the mark. See Johnson, 364 S.W.3d at 294.
We turn then to the evidence supporting the State’s burden as determined by the
indictment and the jury charge.
To the extent that King claims the State failed to prove that King’s omission of water or
food resulted in serious bodily injury to Ava, the State suggests that the evidence of Ava’s
malnourishment and dehydration was sufficient to establish the element of serious bodily injury,
and we agree. Lenfest testified that Ava had an acute kidney injury, severe dehydration, and that
her cause of death was due to “[c]omplications of neglect, including malnutrition and
hypernatremic dehydration.” On cross-examination, Lenfest explained that hypernatremic
dehydration did not “necessarily mean malnutrition,” but it could be caused by a number of
circumstances, including a lack of fluid intake. He said he thought Ava was dehydrated as a
result of malnutrition. Lenfest also acknowledged that Ava had “fecal material in her small and
19 large intestines,” and although that indicated she was receiving “some nutrition, . . . the end
result [was] that it [was not] enough nutrition.” Based on Lenfest’s medical testimony, the jury
could find that malnutrition and hypernatremic dehydration qualified as “serious bodily injury.”
See Proo, 587 S.W.3d at 811.
King’s challenge to the sufficiency of the evidence to support his conviction centers on
an alleged paucity of evidence demonstrating his knowing mental state. King challenges the
sufficiency of the evidence to show that he was aware with reasonable certainty that serious
bodily injury would result from his failure to provide food or water to Ava.
“Mental state is rarely proved through direct evidence and almost always depends on
circumstantial evidence.” Dorch v. State, 596 S.W.3d 871, 885 (Tex. App.—San Antonio 2019,
pet. ref’d) (citing Hart v. State, 89 S.W.3d 61, 64 (Tex. Crim. App. 2002)). “Each fact need not
point directly and independently to the guilt of the appellant, as long as the cumulative force of
all the incriminating circumstances is sufficient to support the conviction.” Id. (quoting Thomas
v. State, 444 S.W.3d 4, 8 (Tex. Crim. App. 2014)). “Knowledge . . . may be inferred from any
facts which tend to prove [its] existence, ‘including the acts, words, and conduct of the accused,
[] the method of committing the crime[,] and . . . the nature of wounds inflicted on the victim[].”
Id. (third alteration in original) (quoting Hart, 89 S.W.3d at 64).
Reeder testified that Ava lost weight during her first year of life and that her parents were
instructed to take additional measures to help her gain weight. Reeder noted that Mother stopped
attending the well-child visits after Ava’s six-month visit, and King brought Ava in by himself.
After Ava’s twelve-month well-child visit, which she came in for when she was seventeen
20 months old, King did not bring her in again. Ava missed her eighteen-month and twenty-four-
month well-child visits. At one of the three pediatrician appointments King took Ava to after her
six-month well-child visit, Ava had lost weight, and at another, she was notably thin for her age
and had poor weight gain. At all three, King was instructed to take measures to increase Ava’s
caloric intake. Yet, according to Reeder, Ava was three pounds underweight—weighing just
twenty-one pounds at the time of her death—eleven months after her last well-child visit.
Regarding Ava’s dehydration, Reeder testified that
our thirst mechanism is one of the strongest reflexes that we have, meaning that if we are starved to the point or dehydrated to a certain point, our thirst mechanism will kick in, and we will do anything that we can to try to get liquid or try to rehydrate ourselves, do things that we would never think of doing: drinking out of a toilet, drinking ocean water even though we know [that is] bad for us.
Reeder testified that “it is extremely rare for a person who otherwise has access to liquids or
fluids to get themselves to a point of hypernatremic dehydration, especially to a fatal state in a
person who otherwise has the ability to get to liquids or fluids.” Reeder said that a crib a child
could not get out of would be a “barrier” that would keep the child from being able to hydrate
herself. Espinoza testified that Ava could not get out of the crib on her own.
Reeder further testified that Ava would have been hungry, thirsty, very weak, and very
fussy or irritable in the hours before her death. Reeder stated that fifteen hours of uninterrupted
sleep was several hours more than what is common for a twenty-eight-month-old child. Reeder
testified that Ava’s abnormal appearance in the last several days of her life would have prompted
a reasonable caregiver to provide medical treatment, food, or water. Reeder opined that Ava’s
direct result of death was “[p]hysical neglect with restriction of food and water causing the
21 hypernatremic dehydration and then evidence of prior medical neglect . . . due to the lack of
appropriate medical care and follow up.”
That medical testimony not only established Ava’s symptoms near the end of her life and
how they would have alerted a reasonable caregiver to provide for her; it also showed that King
and Mother had not provided Ava with sufficient nutrition at earlier times in her life. In
particular, because King attended Ava’s last three pediatrician appointments by himself, he alone
received the instructions to increase Ava’s caloric intake through increasing the concentration
and amount of her formula and adding PediaSure to her diet.
Further, testimony from several witnesses indicated that King kept water, other
beverages, and snack foods in the house. There was also testimony that King had a snack drawer
in the refrigerator and that Ava could access it. Yet photographs of the kitchen show that the
handles on both the refrigerator and the freezer sections of the refrigerator were missing. And
while the photographs show cases of water on the floor, and a large bottle of juice and several
sippy cups on the kitchen counter, there was no testimony indicating Ava could reach or open
any of those containers herself. Testimony established that Ava could not get out of her crib,
and, had she been able to, baskets of laundry in the hall and a baby gate in the kitchen would
have kept her from being able to reach King, the only adult available to provide her with food or
water, had she been strong enough to ask for it.
Finally, the evidence establishes that King started using cocaine in February 2023, before
Ava’s death in April, and he was the sole caregiver much of the time because Mother was often
absent. While there was no evidence that King was using cocaine on the date of Ava’s death, the
22 evidence is undisputed that he left her in her crib for over fifteen hours, and when he found her,
she was dead, with medical evidence that she had died of malnutrition and dehydration.
King claims that because “injuries caused by failure to provide nourishment . . . occur
over a period of time,” the evidence is insufficient because there is no proof that Ava went
without food or water other than the fifteen-hour period before her death. At one point, Reeder
testified that fifteen hours without water would be insufficient to cause Ava’s death. But Reeder
later testified that “in a child like [Ava] who may be severely malnourished and already having a
degree of dehydration, [fifteen] hours without anything, without any fluids, yes, may be enough
to cause death.”
Considering all the evidence, presuming that the jury resolved any conflicting inferences
in favor of the verdict, and deferring to the jury’s determinations as to the weight and credibility
of the evidence, as we must, see Braughton, 569 S.W.3d at 608, we conclude the evidence here
supports a reasonable inference that King was aware of Ava’s malnourished and dehydrated
condition and that his failure to provide her with sufficient food or water was reasonably certain
to cause her serious bodily injury. See Dorch, 596 S.W.3d at 886; Proo, 587 S.W.3d at 809–11.
We overrule King’s sole point of error.
23 IV. Conclusion
We affirm the trial court’s judgment.
Jeff Rambin Justice
Date Submitted: January 23, 2026 Date Decided: March 11, 2026
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