Father raises questions after daughter's medical records changed

UNION COUNTY, N.C. — A Union County father is demanding answers after he says medical records that prove his 2-year-old daughter was sexually abused were changed without new medical evidence.

The father, who believes his child was sexually abused by a relative, gave Whistleblower 9's Paul Boyd permission to review his daughter's medical records. The dad signed a waiver and officials at Carolinas Medical Center-Union provided a portion of her medical file, including the day the alleged abuse was discovered at the hospital.

The documents show that on June 9, 2013 at 12:15 p.m. a 2-year-old girl is brought into the CMC-Union emergency department by her father.

The initial "Psychosocial Report" says that the little girl appears "fearful."

A nurse conducts a "pain assessment" on the child and notes the "occasional grimace" and that she "moans or whimpers."

Then the little girl is examined by a physician assistant who makes specific notes that the child is "anxious, tearful" and has "lesions" on her private parts.

That physician assistant diagnoses the child with "acute urinary tract infection" and confirms there was a "sexual assault."

At 3:15 p.m., the Union County Sheriff's Office is notified. So is the Union County Department of Social Services. Both begin investigations.

The next day, on June 10, 2013, a final diagnosis is entered at the hospital by the attending physician of "urinary tract infection ... child sexual abuse" and "rape."

But then, nearly two months later, on July 25, 2013 the physician assistant downgraded the diagnosis to only a "possible sexual assault."

No one was ever charged and the case was closed.

The Union Country Sheriff's Office provided a statement to Whistleblower 9 that "… the case was fully investigated and there was no evidence to bring charges in this case."

But one year later, the physician's assistant was called to testify about that change of diagnosis in a related child custody case.

Whistleblower 9 obtained an audio recording of her testimony, in which she says that she was "told" to modify her diagnosis without seeing any new medical evidence.

"I was also told ... by a woman who supervises me at the hospital to make a written modification to the note. She didn't command me to do so but it was encouraged to update this note," the physician assistant testified.

An attorney asked, "So it's not something that you were going to do on your own?"

"Not at the time because I had no evidence to nullify the sexual assault," the physician assistant responded.

The judge wanted to know more and asked if she had ever been asked to change a diagnosis before.

"No," she answered.

Then the judge asked if she had "ever done it since" and the physician assistant replied she had not.

Court records don't say who at the hospital allegedly told her to change the diagnosis.

Whistleblower 9 contacted both Carolinas Healthcare System and the Union County Department of Social Services but both declined to comment.

Charlotte attorney James Wyatt has no connection to the case but reviewed the basic facts for Channel 9.

"My first reaction is that the diagnosis is very drastic and alarming," Wyatt said.

He wanted to know exactly what steps were taken during the investigation in 2013. That was a tumultuous year for the Union County Department of Social Services after a case worker turned a blind eye to the abuse of an 11-year-old boy in her care. The boy was found handcuffed on his porch with a dead chicken around his neck.

"Throughout periods of time, including 2013, there's been instances where DSS has been overloaded. Where they haven't been able to do the proper investigations. There just isn't enough man power to do it. There could also be other reasons here. Were they misled about what happened here? Did someone throw this investigation off track? There's a lot of questions that aren't answered," Wyatt said.

The father of the little girl in the sexual abuse case says he just wants answers.

He's been fighting for justice for three years and wants the relative he says is responsible charged. He believes the system failed his daughter and he's worried he's not the only one.

"It's not just my case, I hope if we can get some accountability it can prevent this from happening again," the father said.

He's now asking the FBI to investigate his daughter's case on the grounds of medical fraud and public corruption.

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