{"id":56418,"date":"2021-06-02T16:30:00","date_gmt":"2021-06-02T16:30:00","guid":{"rendered":"https:\/\/one.sightlinemg.com\/navytimes\/uncategorized\/2021\/06\/02\/report-va-oversight-lapses-allowed-pathologists-serious-medical-errors-to-accumulate\/"},"modified":"2026-08-08T09:31:09","modified_gmt":"2026-08-08T09:31:09","slug":"report-va-oversight-lapses-allowed-pathologists-serious-medical-errors-to-accumulate","status":"publish","type":"post","link":"https:\/\/one.sightlinemg.com\/navytimes\/veterans\/2021\/06\/02\/report-va-oversight-lapses-allowed-pathologists-serious-medical-errors-to-accumulate\/","title":{"rendered":"VA oversight lapses allowed pathologist\u2019s serious medical errors to accumulate: watchdog report"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Inadequate oversight by Veterans Affairs senior leaders and a fear of whistleblower reprisal among other staffers allowed a department pathologist to make thousands of serious medical errors, including the deaths of at least two patients, according to the findings of a scathing investigative report released Wednesday.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The findings from the VA Inspector General focus on the actions of <a href=\"https:\/\/www.militarytimes.com\/news\/pentagon-congress\/2019\/08\/20\/former-va-medical-official-charged-in-deaths-of-three-patients\/\" target=\"_blank\">Robert Morris Levy<\/a>, a former staffer at the Veterans Health Care System of the Ozarks in Arkansas from 2005 to 2018.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In January, he was sentenced to 20 years in prison for involuntary manslaughter and mail fraud connected to the mistakes, brought to light after several years of investigation by VA and law enforcement authorities.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The critical report also comes less than a month after <a href=\"https:\/\/www.militarytimes.com\/veterans\/2021\/05\/13\/can-veterans-affairs-officials-spot-another-serial-killer-hiding-in-their-midst\/\" target=\"_blank\">another damning set of findings<\/a> on institutional failures connected to a former VA nursing assistant in West Virginia who killed at least seven patients, tragedies the inspector general said may have been prevented with better communication and oversight by facility leaders.<\/p>\n\n\n\t<aside class=\"smg-interstitial-link wp-block-smg-interstitial-link\">\n\t\t<a href=\"https:\/\/one.sightlinemg.com\/militarytimes\/news\/pentagon-congress\/2021\/05\/13\/can-veterans-affairs-officials-spot-another-serial-killer-hiding-in-their-midst\/\" class=\"smg-interstitial-link__inner\">\n\t\t\t\t\t\t\t<div class=\"smg-interstitial-link__media\">\n\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"200\" src=\"https:\/\/one.sightlinemg.com\/wp-content\/uploads\/2026\/08\/AP20196755802696.jpg.jpg?w=300\" class=\"smg-interstitial-link__image wp-post-image\" alt=\"\" \/>\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"smg-interstitial-link__content\">\n\t\t\t\t<span class=\"smg-interstitial-link__kicker\">Related<\/span>\n\t\t\t\t<h3 class=\"smg-interstitial-link__title\">Can Veterans Affairs officials spot another serial killer hiding in their midst?<\/h3>\n\t\t\t\t\t\t\t\t\t<p class=\"smg-interstitial-link__excerpt\">In the wake of a former staffer being imprisoned for murdering seven patients, VA watchdogs warn that changes need to be made across the department&#039;s health system.<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/a>\n\t<\/aside>\n\t\n\n\n<p class=\"wp-block-paragraph\">In Levy\u2019s case, officials found \u201ca culture in which staff did not report serious concerns in part because of a perception that others had reported [the problem] or they were concerned about reprisal.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Senior leaders who knew about Levy\u2019s struggle with alcoholism and past unethical behaviors failed to fully monitor his work, even amid concerns that he may be manipulating medical reports. Investigators also criticized leaders who \u201cfailed to promote a culture of accountability\u201d at the site.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u201cAny one of these breakdowns could cause harmful results,\u201d the report states. \u201cOccurring together and over an extended period of time, the consequences were devastating, tragic, and deadly.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Levy was arrested in March 2018 for suspicion of drunk driving in a parking lot near the VA hospital while he was supposed to be on duty. He was fired then, and officials initiated a review of his past work to look for any potential patient care problems.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">They found more than 3,000 errors, including 589 \u201cmajor diagnostic discrepancies\u201d with serious repercussions for patients. In at least two cases, Levy overlooked clear evidence of cancers which, if treated earlier, may have saved the patients\u2019 lives.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Supervisors had suspected Levy was drinking alcohol while on duty as far back as 2015. He was temporarily suspended In 2016, but reinstated by department and state medical officials after completing an addiction treatment program.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">But prosecutors said Levy cheated drug tests and falsified records to cover up his relapses. As a result, he continued reviewing sensitive patient medical information while intoxicated, potentially issuing incorrect or dangerous diagnoses for thousands of veterans.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The IG report said some of those mistakes could have been prevented with better policies and procedures at the medical center.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Under VA rules, much of Levy\u2019s work should have been reviewed by a second department pathologist, but Levy for years altered records to make it appear as if his work had undergone that extra check. Officials higher up missed the forgeries in their work.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Investigators also noted that Levy\u2019s alcohol use on the job was noticed by multiple staff members, but most opted not to report the problems because of fear of reprisal from the doctor and his supervisors and confusion surrounding the chain of command. One staff member who did report the improper behavior \u201cfelt belittled\u201d by leadership after doing so.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">And investigators said that officials failed to follow up on Levy\u2019s past alcohol-related legal issues before his 2005 hiring, which might have disqualified him from the sensitive patient work. The inspector general found similar problems with pre-hiring background checks in the West Virginia case.<\/p>\n\n\n\t<aside class=\"smg-interstitial-link wp-block-smg-interstitial-link\">\n\t\t<a href=\"https:\/\/one.sightlinemg.com\/militarytimes\/news\/pentagon-congress\/2019\/08\/20\/former-va-medical-official-charged-in-deaths-of-three-patients\/\" class=\"smg-interstitial-link__inner\">\n\t\t\t\t\t\t\t<div class=\"smg-interstitial-link__media\">\n\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"225\" src=\"https:\/\/one.sightlinemg.com\/wp-content\/uploads\/2026\/08\/6354516141_94aaca4595_o.jpg.jpg?w=300\" class=\"smg-interstitial-link__image wp-post-image\" alt=\"\" \/>\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"smg-interstitial-link__content\">\n\t\t\t\t<span class=\"smg-interstitial-link__kicker\">Related<\/span>\n\t\t\t\t<h3 class=\"smg-interstitial-link__title\">Former VA medical official charged in deaths of three patients<\/h3>\n\t\t\t\t\t\t\t\t\t<p class=\"smg-interstitial-link__excerpt\">Robert Morris Levy also faces multiple counts of fraud related to his attempts to cover up substance abuse while on duty.<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/a>\n\t<\/aside>\n\t\n\n\n<p class=\"wp-block-paragraph\">In a statement, VA Inspector General Michael Missal called the findings \u201ca reminder for all VHA facilities of the potential consequences of failing to have open communications and an effective patient safety program.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">VA officials promised reforms in response to the case.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u201cWe are deeply saddened by the harm Dr. Levy committed against our veterans,\u201d Richard Stone, acting under secretary for health at VA, said in a statement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u201cOur medically vulnerable patients trusted him with their care and several lost their lives due to his behavior. VHA condemns his actions and is committed to improving processes to ensure safe care for veterans across the system.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In a separate statement, VA officials noted that Levy \u201csought to deceive the government, and VA was not aware of the actions he took to conceal his errors. Once the full extent of his actions was known, VA worked immediately to enact process changes &#8230; that would prevent any provider from causing tragic patient harm.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">VA officials said new policies regarding medical report reviews will be in place by the end of the summer. A full review of facility leadership response and responsibility is expected to be finished by this fall.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Department leaders are also looking into potentially requiring mandatory alcohol testing policy for on-duty staff, following confusion over whether Levy was required to submit to such testing before his 2016 treatment program. VA has also creating a new quality analyst position at focused solely on pathology and laboratory issues.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The full report is available on the <a href=\"https:\/\/www.va.gov\/oig\/\" target=\"_blank\">VA Inspector General\u2019s web site.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A former physician was sentenced to 20 years in prison for the deadly mistakes.<\/p>\n","protected":false},"author":7,"featured_media":94309,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_yoast_wpseo_meta-robots-noindex":"","_yoast_wpseo_meta-robots-nofollow":"","_yoast_wpseo_canonical":"","_acf":"","_yoast_wpseo_primary_category":19,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","_smg_distribution_targets":[]},"categories":[101,23,89,12,26,62,19],"tags":[],"coauthors":[3222],"class_list":["post-56418","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-daily-news-roundup","category-home","category-middle-column","category-news","category-newsletters","category-pentagon-congress","category-veterans"],"acf":{"subheadline":"","legacy_arc_id":"UNWZGXR67JEEZNSCPQYYSP5HRU","arc_canonical_url":"\/veterans\/2021\/06\/02\/report-va-oversight-lapses-allowed-pathologists-serious-medical-errors-to-accumulate\/","remove_feature_photo":false,"is_sponsored":false,"subtype":"","redirect_url":"","disable_inline_ads":false,"native_logo_pretext":"Presented 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