VA's Systemic Failures Allowed Alcoholic Doctor to Keep Job While Making Mistakes That Killed Patients
"The consequences were devastating, tragic and deadly," IG says of convicted former VA employee.
A pathologist at the Veterans Affairs Department operated for years with impunity despite suffering from alcoholism, which led to the significant misdiagnoses and the deaths of some patients.
Robert Levy, a doctor at the Veterans Health Care System of the Ozarks in Fayetteville, Ark., for more than a dozen years, has already received a 20-year prison sentence for his actions, but a new report from the VA inspector general found a pattern of failures by facility leadership that enabled him to provide dangerous care for so long. A review of all of Levy’s cases found 3,000 errors, including nearly 600 “major diagnostic discrepancies.” VA has since notified 34 patients or their families of his faulty practices.
In two of his biggest errors, Levy missed cancer spots and diagnosed the wrong type of cancer. Both mistakes led to incorrect treatment and, eventually, the patients’ deaths.
The IG faulted VA for its handling of Levy dating back to his 2005 hiring, noting his prior arrest for driving under the influence of alcohol and his short-term tenure at his previous job should have raised more red flags. The facility should have implemented stricter oversight of his cases during his two-year probationary period, the IG said.
The VA facility also created an environment that made it easy for Levy to make it look like his work was receiving proper quality control. While the department required a review of a random 10% sample of his diagnoses, Levy had final sign off on any discrepancies that arose. He chaired all three of the panels that reviewed his work and was able to approve it without his colleagues actually providing any feedback. He served as the supervisor to the only other pathologist on staff, leading to a potential conflict of interest in which that employee said he felt any pushback he gave on Levy’s diagnoses would negatively impact his own job security. Levy was also found to have fabricated concurrence statements.
“As Path and Lab Service chief, he was in charge of reporting pathology quality management data to facility leaders including information related to his own pathology practices, which made the process susceptible to subversion,” the IG said. It added the facility’s failure to recognize its flawed processes was “complicated by Dr. Levy’s efforts to conceal his errors.”
Facility management became aware of complaints that Levy was intoxicated at work as early as 2014, the same year it learned of an incorrect treatment that resulted from one of Levy’s diagnostic errors. Levy gave “implausible” excuses in subsequent reports of alcohol on his breath, such as that he drank a lot of juice. The chief of staff at the facility looked into the reports but never substantiated them and Levy went unpunished until 2016, when Levy voluntarily submitted to a blood-alcohol test and was found to be well above the legal limit. Levy then took a leave of absence to receive treatment for alcoholism, but returned to his job a few months later.
The IG faulted VA for failing to take a more aggressive approach in testing Levy upon his return, which it said would have been allowable under federal statute and civil service regulations. Levy was eventually subjected to some urine tests, but later admitted to purchasing a chemical substance that allowed him to pass them despite being intoxicated.
VA failed to create a “culture of accountability” at the facility, the IG found, after it brushed aside employee complaints toward Levy. Some staffers reported fearing reprisal about speaking out, while others said they assumed their efforts would have been ignored anyway.
All of management’s various failures created a perfect storm in which Levy could continue to threaten the safety of the facility’s patients.
“Any one of these breakdowns could cause harmful results,” the investigators said. “Occurring together and over an extended period of time, the consequences were devastating, tragic and deadly.”
The IG recommended that VA more comprehensively assess the competency of its health care hires and that reviews take place without conflicts of interest and management be held accountable for accurate reviews of their employees’ work. The department should also consider developing a mandatory alcohol testing policy, the watchdog said. The IG added the department should consider discipline for Levy’s supervisors.
In addition to his 20-year sentence, which Levy is appealing, the former pathologist was ordered to pay nearly $500,000 in restitution to VA.