A report released by the Veterans Affairs Office of Inspector General found that pathologist Robert Levy misdiagnosed more than 3,000 veterans while routinely reporting to work drunk. Photo by Tasos Katopodis/UPI | License Photo
June 2 (UPI) -- A pathologist at a Veterans Affairs hospital in Arkansas misdiagnosed thousands of veterans resulting in "devastating, tragic and deadly" consequences, according to a report released Wednesday.
The report by the VA's Office of Inspector General found that former pathologist Robert Levy routinely worked while under the influence of alcohol, and leadership at Veterans Health Care System of the Ozarks in Fayetteville, Ark., failed to promote "a culture of accountability" at the facility.
"Any one of these breakdowns could cause harmful results," the report states. "Occurring together and over an extended period of time, the consequences were devastating, tragic and deadly."
Levy, 54, worked at the Arkansas facility for 13 years and a review of nearly 34,000 cases Levy had diagnosed during that period found more than 3,000 errors including 589 "major diagnostic discrepancies" that caused medical harm to patients.
At least 15 of Levy's patients died including a patient in 2012 who underwent a prostate biopsy that Levy reported as benign although reviewers identified cancer in two specimens and a second patient who was treated for small cell cancer based on Levy's diagnosis, although reviewers determined the patient had squamous cell cancer, requiring surgery that was not offered.
Levy was fired in 2018, months after he was arrested on suspicion of driving while intoxicated in the parking lot of a local post office during work hours. In January, he was sentenced to 20 years in prison after pleading guilty to involuntary manslaughter and mail fraud.
He had previously been removed from clinical practice facility in 2016 after a test revealed his blood alcohol content was high during work hours but returned months later after attending a treatment program and agreeing to regular tests for drug and alcohol use.
Despite reports that Levy was observed as "drowsy, glassy-eyed, slurring his words, and with an unsteady gait," urine and blood tests were reported to be negative, although after his dismissal Levy admitted to purchasing a substance online that was "similar to alcohol but more potent" and not detectable using routine tests.
In 2014, Dr. Mark Worley, who served as the facility's chief of staff from 2012 to 2018, told investigators he received "episodic, informal reports related to Dr. Levy's smelling like alcohol or other possible signs of impairment," but concluded that they were "not actionable."
Worley also received a complaint that Levy smelled of alcohol at which point the report states that Levy "gave an implausible excuse for his smelling like alcohol (drinking a lot of juice)." Worley determined that Levy did not smell of alcohol and did not take further action.
The report also found that Levy subverted peer review practices meant to protect against errors and that other pathologists did not review his work or assess his performance when his credentials were up for renewal.
"The OIG concluded that facility leaders did not meet [the Veterans Health Administration's] goal to establish an environment in which staff act with integrity to achieve accountability," the report said.
VA press secretary Terrence L. Hayes told The Washington Post that the agency is "fully committed" to improving protections for patients following the report.
"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," said Hayes. "Once the full extent of his actions was known, VA worked immediately to enact process changes at [the Arkansas facility] and nationally that would prevent any provider from causing tragic patient harm."