Investigative Update

Pathologist’s Errors Associated with 12 Deaths at Arkansas VA

IN AN UPDATE TO A CASE REPORTED LAST YEAR, the investigation at the Arkansas Veterans Heath Care System of the Ozarks and the Veterans Affairs Medical Center in Fayetteville, Ark., now shows that as many as 12 veterans died as a result of this one pathologist’s errors, according to a report by Arkansas KFSM 5 News.

Investigators have now reviewed 33,902 cases that one pathologist handled and of these—3,007 (8.8%) involved an error or misdiagnosis—local media reported in January. The pathologist in question is Robert Morris Levy, MD, whom the VA fired in April 2018 after saying that Levy had been working while “impaired.” During a preliminary review, investigators found that he gave incorrect diagnoses to three veterans who later died. (See “Pathology Errors a Factor in Three Deaths at VA Hospital,” TDR, Oct. 1, 2018.)

Kelvin Parks, Director of the VA health system, reported on Levy’s high rate of errors and said the rate was more than 12 times that of the standard in pathology practice. The Northwest Arkansas Democrat Gazette reported that the normal error rate for pathology results nationwide is 0.7%.

During a meeting in Fayetteville on Jan. 28, the health system released the latest findings in the investigation. News media said about 100 veterans attended the meeting. The Veterans Health Care System of the Ozarks serves veterans in 23 counties in Northwest Arkansas, Southwest Missouri, and Eastern Oklahoma.

As TDR reported earlier, Levy had been Chief of Pathology at the Veterans Health Care System of the Ozarks before he was fired. At that time, media reports said Levy “denied he was impaired on duty.”

VA officials said it was necessary to review the 33,902 cases, prioritized by level of risk, because that was the number of cases Levy had been involved with since he was hired in 2005, the newspaper reported.

The case review was expected to last until the end of last year because the University of Arkansas for Medical Sciences had sent nine pathologists to work at the Fayetteville Veterans System site fulltime, the newspaper reported. By Oct. 1, the beginning of the federal fiscal year, the VA system wanted to bring in more pathologists from outside of Arkansas, it added.

Working While Impaired?

One of the most pressing questions in the case was whether Levy worked while impaired at the Fayetteville Veterans Administration Hospital. The pathologist confirmed that he had worked while impaired by alcohol in 2016 but said he did not work while impaired after that, the newspaper reported.

The Inspector General for the Veterans Affairs Office is investigating why Levy was retained at the VA system as a pathologist after his first reported impairment, officials said. As TDR reported, Levy was suspended in March 2016 for being impaired, but, after counseling, returned to work in October 2016. In October 2017, Levy was no longer involved in clinical work after the hospital discovered a second instance of working while impaired, and after a review by staff in the personnel department, Levy was fired, the newspaper added.

The newspaper reported that the U.S. Attorney for the Western District of Arkansas also was investigating.

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