Leadership failures at a Department of Veterans Affairs hospital in Arkansas allowed a pathologist to work with little challenge to his competence and authority, resulting in more than 3,000 diagnostic errors and at least two deaths, the VA's top health watchdog reported Wednesday.
A VA Office of Inspector General dive into the case of Robert Morris Levy, a former VA pathologist who was sentenced in January to 20 years for involuntary manslaughter and mail fraud, has shown that "deficiencies in the quality management processes" and "concerns about reprisal" at the Veterans Health Care System of the Ozarks allowed the doctor's misconduct to go unchallenged.
Levy was employed at the VA medical center from 2005 to 2018, when he was fired after being arrested for driving under the influence. But he had been suspected of being impaired at work as early as 2014. In 2016, after testing positive for a high level of alcohol and being placed on probation, he purchased an intoxicant via the internet that would not show up on routine testing -- a move that would allow him to return to work, according to the criminal investigation.
A VA OIG audit of more than 34,000 pathology cases at the medical center found more than 3,000 errors, including 589 "major diagnostic discrepancies" interpreted by Levy. It also revealed at least two deaths, including a patient who had identifiable prostate cancer that Levy reported as benign and a lung cancer patient who did not receive appropriate treatment for the disease because Levy said it was a different type of cancer.
The VA OIG said that the facility's quality management system should have triggered tighter scrutiny of Levy but did not, beginning when he was hired after disclosing he had a 1996 drunk driving conviction.
John Daigh, VA assistant inspector general for health care inspections, said the disclosure should have generated close supervision of the pathologist during his probationary period, but Levy received very little oversight.
He was soon promoted to a position where he was able to set policy and manipulate data -- a failure that allowed him to go unchallenged, even by subordinates who questioned his diagnoses, Daigh said.
With Levy having oversight of the lab and instituting loose procedures, such as documenting cases on sticky notes, he was able to alter or dismiss objections to his interpretations, the VA OIG found.
"The use of informal documentation did not allow ready tracking or promote accountability," Daigh wrote in a 102-page report released Wednesday.
According to the report, hospital leadership also failed to manage Levy, who was suspected of being impaired at work on several occasions.
In one incident in 2014, the hospital's chief of staff received a complaint that Levy smelled of alcohol. When the chief went to investigate, Levy gave an "implausible excuse for his smelling like alcohol (drinking a lot of juice)." The chief of staff couldn't smell alcohol and did not take any action.
In 2016, Levy was suspected of being under the influence, with staff reporting that he was loud, abrupt, slurring his words and not easily understood.
But his privileges were not revoked nor was he fired, with the chief of staff citing Levy's retirement from the Air Force as an officer in good standing and a lack of evidence of patient harm as reasons for not doing a full investigation.
After the 2016 incident, Levy himself contacted the Louisiana State Board of Medical Examiners -- one of four boards to which he was licensed -- to say his alleged behavior and high blood alcohol content were due to the interaction of blood pressure and over-the-counter sinus medications, along with being on a ketogenic diet.
Levy returned to duty following that incident but came under additional scrutiny that later led to his dismissal.
The IG noted that, when fellow staff members were interviewed, they said they feared reprisal if they reported their long-standing concerns about Levy.
"A staff member, who was told whistleblowers were fired, was worried about reprisal and did not know how to challenge a doctor," the VA OIG wrote.
"Any one of these breakdowns could cause harmful results. Occurring together and over an extended period of time, the consequences were devastating, tragic and deadly," Daigh added.
In addition to jail time, Levy was ordered to pay restitution to the VA of $497,745.70 -- just a fraction of the $2.1 million it cost to conduct the VA OIG "look back" study that resulted in the report, "Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas."
Daigh made 10 recommendations to the Veterans Health Administration and two to the Ozarks VA for improvements. They include:
- Improving assessments of newly hired providers
- Reviewing credentialing and privileging policies
- Improving pathology procedures and oversight of pathology and laboratories
- Bolstering quality management processes involving external non-VA assessments
- Ensuring that the Veterans Health Care System of the Ozarks evaluates its climate regarding reports of safety concerns and patient care
VA officials largely agreed with the recommendations and said they have already issued guidance for evaluating specialty care providers and improving performance monitoring standards for pathologists.
"We are deeply saddened by the harm Dr. Levy committed against our veterans. Our medically vulnerable patients trusted him with their care and several lost their lives due to his behavior. VHA condemns his actions and is committed to improving processes to ensure safe care for veterans across the system," Acting VA Under Secretary for Health Dr. Richard Stone wrote in a response to the report.
Following Levy's sentencing, VA Inspector General Michael Missal said he hopes the outcome gives family members "some small measure of comfort."
"This sentence should send a strong message that those who abuse their positions of trust in caring for veterans will be held accountable," he said.
-- Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime.