An investigation into a prominent VA hospital in Arkansas shows just how dangerous drinking on the job can be. A pathologist at the center was let go for having a drinking problem that affected his work, but his actions went unchecked for years. Now, regulators believe he’s at least partially responsible for 15 patient deaths and more than 3,000 diagnostic errors. Administrators failed to address his actions until it was too late.
Drinking on the Job
Records show Robert Morris Levy worked as a pathologist at the Veterans Healthcare System of the Ozarks from 2004 to 2018 before he was fired. His colleagues were concerned that he was drinking on the job as early as 2014. In 2016, he was placed on administrative leave after testing positive for high levels of alcohol. That’s when he started buying an intoxicant online that would prevent alcohol from showing up during regular screenings.
This allowed him to work under the influence for years, according to the criminal investigation.
An investigation from the Office of the Inspector General (OIG) reviewed more than 34,000 pathology cases at the center and found more than 3,000 diagnostic errors, including 589 “major diagnostic discrepancies” as a result of Levy’s actions. These mistakes led to unnecessary medical treatments, delayed care, and the death of 15 patients.
Regulators found an error rate of nearly 10% on the part of Levy, compared to the average pathologist misdiagnosis rate of 0.7%.
In one case, a veteran had identifiable prostate cancer, but Levy diagnosed it as benign. In another case, a veteran didn’t receive the appropriate lung cancer treatment because Levy misdiagnosed their disease.
Investigators say Levy’s actions should have triggered an automatic review from his supervisors, but a negative work culture and relaxed quality standards allowed Levy to continue working under the influence.
Instead of penalizing Levy for his behavior, records show he was promoted to a position that involved setting policies and manipulating data, which allowed him to go unchecked for years, even when his subordinates started raising concerns about his behavior.
By this point, Levy had full control of the lab, where he would implement loose procedures like documenting cases on sticky notes. He would regularly dismiss anyone who objected to his behavior or leadership style.
“The use of informal documentation did not allow ready tracking or promote accountability,” John Daigh, VA assistant inspector general for health care inspections, said in the official report.
Leadership also failed to hold Levy accountable for his actions. In one instance, the hospital’s chief of staff received a complaint that Levy smelled of alcohol. When he went to investigate, he said Levy gave an “implausible excuse for his smelling like alcohol (drinking a lot of juice).” In the end, the chief of staff didn’t smell alcohol and let Levy return to work.
In 2016, Levy’s staff complained that he was being loud, incoherent, and slurring his words, but again he was allowed to walk away unchallenged. The chief of staff cited his retirement from the Air Force and his good standing as reasons for not opening an investigation.
During private interviews, the OIG also noted that staff said they feared retaliation from Levy if they reported his behavior on the job.
“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
Uncovering the Full Extent of the Damage
Levy was let go in 2018 and subsequently arrested for his actions in 2019. During his plea agreement, Levy acknowledged several of his crimes, including diagnosing lymphoma in a veteran who actually had small-cell carcinoma and falsifying the patient’s medical record to state that a second pathologist agreed with the diagnosis; the patient later died. He also admitted to using 2-methyl-2-butanol on the job so the intoxicant wouldn’t show up in his blood.
As part of the plea deal, Levy 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.
The VA Healthcare Center of the Ozarks released a statement following his conviction: “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. 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.”
The center also tried to excuse itself from any wrongdoing by saying that it took Levy’s actions seriously. “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 the VA was not aware of the actions he took to conceal his errors. Once the full extent of his actions was known, the VA worked immediately to enact process changes at VHSO and nationally that would prevent any provider from causing tragic patient harm.”