A federal investigation found that an Arkansas doctor concealed his substance abuse and erroneous diagnoses from supervisors and his deputy pathologist.
FAYETTEVILLE, Ark. (CN) — Federal investigators released a report Wednesday describing an alcoholic Arkansas pathologist’s thousands of errors that harmed hundreds of Veterans Affairs hospital patients, causing more than a dozen deaths.
Robert Morris Levy was sentenced to 20 years in federal prison in January after a grand jury indicted him in 2019 for the involuntary manslaughter of three patients he had misdiagnosed before falsifying medical records to hide the mistakes he made at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, where he was chief of pathology and laboratory medical services.
On Wednesday, the Department of Veterans Affairs’ Office of Inspector General released a report on issues at the Arkansas hospital, concluding an Office of Healthcare Inspections investigation that began in the spring of 2018.
Officials analyzed Levy’s nearly 34,000 cases and found more than 3,000 mistakes, including 589 “major diagnostic discrepancies” between his 2005 hire until his removal in 2018, after he was arrested for drunk driving.
The OIG investigators say Levy admitted to 30 years of alcoholism, noting that he was removed from clinical practice at the hospital in 2016 for just a matter of months before he was reinstated upon the conclusion of a rehabilitation program.
Levy also said he would ingest a drug known as 2-methyl-2-butanol, which he described as similar to alcohol but more potent, to avoid being detected in the hospital’s drug tests.
He manipulated hospital records and data, altering his deputy pathologist’s reviews to make the second opinions appear to concur with Levy’s erroneous diagnoses. Investigators blamed senior staff at the hospital for failing to intervene in Levy’s misconduct.
“The OIG found a culture in which staff did not report serious concerns about Dr. Levy’s conduct in part because of a perception that others had reported or they were concerned about reprisal,” the report states. “Occurring together and over an extended period of time, the consequences were devastating, tragic and deadly.”
The report summarizes Levy’s negligent treatment of five patients, each of whom were unable to properly treat their ailments as a result of Levy’s hasty and inaccurate diagnoses and treatments.
One patient underwent chemotherapy and radiation treatment for lymphoma, though they were suffering small cell carcinoma, which Levy had noted five days after initially diagnosing the patient with lymphoma but never communicated to the patient’s health care providers. This was discovered just two weeks before the patient’s death in 2014.
In another case, Levy told a patient that their prostate biopsy results were benign; when reviewers looked at the six biopsy specimens again in 2018, they noticed cancer in two of them. By then, only end-of-life treatment was available for the patient, who died in 2020.
The report says that Levy’s supervisor, chief of staff Mark Worley, had been informally told by staff as early as 2014 that Levy smelled of alcohol while working, or had noticeable hand tremors and exhibited red, glassy eyes.
That same year, a VA review of Levy’s cases found some of his incorrect diagnoses, but neither Worley nor any other executive hospital staff took further action or implemented stricter monitoring of Levy’s behavior after the discovery, according to Wednesday’s report.
“The failure of facility leaders to take meaningful action after reports of impaired behavior may have preempted further attempts to raise issues of concern,” the report’s conclusion states. “Facility leaders should create an atmosphere where staff are free to comment on ways to improve care and have honest, open discussions to better clinical or administrative practice.”
The report concludes with 12 recommendations for the Department of Veterans Affairs, its under secretary for health and the director of the Fayetteville hospital campus to implement.
Worley, Levy’s supervisor, left the hospital in 2018 to work as a psychiatrist in a Fayetteville community clinic.