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A report from the Veterans Administration Office of Inspector General offers a devastating inside look at errors made by a pathologist with the VA hospital in Arkansas.

Robert Morris Levy began working at the VA facility in Fayetteville, Arkansas in 2005. By the time his employment as Pathology and Lab Service Chief was terminated, Dr. Levy was found to have made more than 3,000 medical errors, including 589 “major diagnostic discrepancies.”

As noted in the report of the Inspector General, the diagnostic errors of Dr. Levy had life-changing and fatal consequences as patients succumbed to missed and erroneous cancer diagnosis.  By his own admission, Dr. Levy had been an alcoholic throughout the tenure of his employment at the VA, and was often impaired on the job.

In 2016, Dr. Levy was removed from clinic duties due to a high blood alcohol content (BAC).  Following a treatment program, Dr. Levy returned to his clinical practice.  While his urine and blood tests revealed no drugs or alcohol, Dr. Levy was observed to be impaired, slurring words, and unable to walk straight in October 2017—still his random drug screens remained negative. At that point, hospital leadership suspended him, suspecting that his standard of care could be a risk to patient wellbeing.  While suspended, he was arrested on suspicion of driving impaired in March, 2018 and he was terminated by the VA in July of that year.

When questioned, Dr. Levy said he had been taken the drug 2M2B that has effects more potent than alcohol, but is undetectable by standard testing. In 2019, criminal charges were filed against him, and in 2020 Dr. Levy pled guilty to mail fraud and involuntary manslaughter.  He was sentenced in January, 2021 to 20 years in prison and restitution of almost $500,000.

As damning as the unconscionable behavior of Dr. Levy was the environment and culture at the VA facility where he worked.  Dr. Levy manipulated quality management data and processes mostly unperturbed until the last years of his tenure with the VA.

In addition to the overt negligence practiced by Dr. Levy, the VA report found “facility leaders failed to promote a culture of accountability.”  Investigators found that staff did not report problems with Dr. Levy for fear of retaliation.  Staff also thought others had reported his behavior, so there was no need for personal exposure in doing the same.

Because Dr. Levy developed and maintained the pathology lab quality management program, it was easy for him to systematically thwart the program as well as the results of oversight committees on which he was Chair. Given lax institutional oversight and negligible accountability on the part of staff, Dr. Levy got away with murder.

Dr. Levy has appealed his sentence.

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