Arkansas VA leaders missed signs pathologist tied to 15 patient deaths was drinking on job: OIG

A new investigation is citing oversight failures, a negative culture and relaxed quality standards at Fayetteville, Ark.-based Veterans Health Care System of the Ozarks as factors allowing a routinely intoxicated pathologist to misdiagnose thousands of veterans, sometimes with serious or fatal consequences.

For more than a decade, hospital officials led by former chief of staff Mark Worley ignored warning signs and subsequently allowed Robert Levy, a former Veterans Health Administration pathologist, to make mistakes that delayed care and led to unnecessary treatment for some patients, according to findings published June 2 by the VA's Office of Inspector General. 

A team of external pathologists examined almost 34,000 cases diagnosed by Mr. Levy during his 12 years at the facility and found errors in more than 3,000 cases, reports The Washington Post. Overall, 589 errors involved major mistakes that caused medical harm, with at least 15 veterans dying. During his time at the facility, the team found a consistent clinical error rate of 10 percent for Mr. Levy's diagnoses, compared to the average pathologist misdiagnosis rate of 0.7 percent.

Mr. Levy, who served as the hospital's chief pathologist at the time, was fired in 2018 and arrested in 2019. Following a plea agreement, he received a 20-year prison sentence for involuntary manslaughter and mail fraud and was ordered to pay about $498,000 in restitution to the VA. Mr. Levy admitted to diagnosing lymphoma in a veteran who actually had a small-cell carcinoma and falsifying the patient's medical record to state that a second pathologist agreed with the diagnosis; the patient later died.  

Mr. Levy also admitted to scheming to hide his excessive substance use, frequently taking 2-methyl-2-butanol to mask the alcohol in his blood, reports the Post.

Hospital leaders "failed to promote a culture of accountability" that would have led more staff members to report concerns, according to the OIG. Instead, staff feared voicing concerns may lead to retaliation from leadership.

Mr. Worley retired from the facility in 2018, his attorney told the Post. He faced no formal consequences from the VA for Mr. Levy's case. When the scandal became public, Bryan Matthews, former director of the hospital, was transferred to lead VA's Gulf Coast Veterans Health Care System in Biloxi, Miss., where he still works, according to the Post.

"The Veterans Health Care System of the Ozarks and the Department of Veterans Affairs is truly saddened at the pain victims and families endured at the hands of this pathologist," a spokesperson for the organizations told Becker's in an emailed statement. "The Department assures Veterans that we are fully committed to improving our processes and systems moving forward to prevent a situation like this from happening again. VA has begun the process of addressing many of the OIG's recommendations and expects to complete the remainder by May 2022.

"In October 2017, VHSO leadership received reports of possible impairment of a staff pathologist, immediately removed him from clinical practice and subsequently terminated him in April 2018, independent from the OIG investigation. An external review team conducted a thorough review of all cases read by the pathologist and sent a letter to all Veterans included in the review. Veterans or their family members who had a serious misdiagnosis were notified in person; others were notified through the clinical disclosure process. 

"The investigations into this matter revealed that the pathologist sought to deceive the government, and VA was not aware of the actions he took to conceal his errors. Once the full extent of his actions was known, VA worked immediately to enact process changes at VHSO and nationally that would prevent any provider from causing tragic patient harm.

"VA has strengthened internal controls by ensuring no provider can review his or her own work and by providing more stringent oversight, policy and processes."

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