Pathologist inquiry finds 3 deaths at VA hospital in Arkansas

NWA Democrat-Gazette/J.T. WAMPLER Veterans Healthcare of the Ozarks.
NWA Democrat-Gazette/J.T. WAMPLER Veterans Healthcare of the Ozarks.

FAYETTEVILLE -- Three deaths are among the 11 confirmed, serious cases in which a pathology report was wrong, according to findings in an ongoing review of an impaired pathologist's work at the Veterans Health Care System of the Ozarks.

The review has found 256 cases in which the pathology report missed the diagnosis with possibly severe consequences ranging from extended, avoidable hospitalization to lasting disability or death, Interim Director Kelvin Parks said Monday. Parks spoke to a crowd of about 30 at an 8 a.m. town hall meeting.

Officials don't know yet in most of the 256 cases if the misdiagnosis had any serious consequences, but serious consequences were confirmed in 11 of those cases, Parks said. Patients in three of the 11 cases died. Misdiagnosis is believed to be a factor in at least one death, according to earlier statements by the Veterans Department. The other two are still under review, Parks said.

A total of 14,980 of the 33,806 cases have been reviewed so far, he said. Of those reviews, 6,822 were of autopsy results, he said.

Of those reviewed, 9,979 have no errors, Parks said. Another 863 appeared to have errors with no lasting consequences to the patients involved, but those cases will receive further review to make sure, he said. Another 3,882 reviews are complete but a final report is not finished, Parks said.

The Ozarks system sent a letter Monday to patients and families where final results are available, Parks said.

The review includes every case the pathologist involved worked on since his hiring in 2005. The cases under review are prioritized by risk, Parks has said.

The review began after administrators discovered a pathologist at the system's hospital in Fayetteville tested samples while impaired, administrators said at the June news conference. The pathologist, Dr. Robert Morris Levy of Fayetteville, confirmed in an earlier interview he worked while impaired with alcohol in 2016, but said he didn't work while impaired afterward.

Levy acknowledged he's the pathologist involved, although the system won't confirm, saying it's a personnel matter, spokesman Wanda Shull has said. Levy was fired in April, according to administrators. He was suspended in March 2016 for being impaired, but he returned to work that October after counseling and after a check of his work found no errors at the time.

Levy was again taken off clinical work in October 2017 after what the hospital described as a second instance of working while impaired. His dismissal in April came after a personnel review.

Attendees at Monday's meeting asked what procedures were in place to make sure such errors are not repeated. Parks said an internal review of the Ozark system's procedures is underway. Not only that, but "the entire VA system is changing its review process because of this incident," he said.

Details will be released later, Parks said.

"We're building this airplane as we fly it," he said. "There is no precedent or procedure for a look-back of this magnitude."

In response to a question from an audience member, Parks confirmed the direct supervisor of the pathologist involved retired after the matter came to light. Parks did not name the supervisor.

Center staff also confirmed someone has filed an administrative tort claim with the U.S. Veterans Department, which allows a person to sue the federal government, if granted. The specifics of the claim are confidential.

The system is keeping up with current pathology work as the review goes on, Parks said, thanks to assistance from both outside pathologists and such specialists within the Veterans Department in the region. The center has one of two pathology positions filled.

Monday was the third town hall meeting since the initial June 18 news conference announcing the problem.

Michael Kalagias, a Libertarian Party candidate for Congress, is one of the veterans who received a letter in June informing him his diagnosis was under review. He said he appreciated how the system was keeping those affected informed, "but going up from a few missed diagnoses to more than 800 is not a trending in a good direction."

There is a measure before the U.S. Senate to limit the Veterans Department's liability in cases and shorten the time in which lawsuits could be filed after an incident, Kalagias said. The bill passed the House last year, long before any problems at the system came to light. H.R. 1215 would limit noneconomic damages to $250,000. The time limit for filing a lawsuit would be cut from three years to one.

"I wonder how many people affected by this review are having to hurry up and decide to file something because they know H.R. 1215 is out there," he said.

Parks expects the review to be finished by Dec. 31, thanks in large part to an agreement with the University of Arkansas for Medical Sciences to provide nine pathologists to work at the Fayetteville veterans system site full time. The system will bring in more pathologists from outside the state, but that will have to wait until the beginning of the new federal fiscal year on Oct. 1, he said.

A final report will be made public in January, he said.

The Veterans Affairs Office of Inspector General is investigating the retention of the pathologist after his first reported impairment, Parks said. There's no timeline on the inspector general's report, he said. In addition, Parks has launched an internal investigation to find "who knew what when," he said.

The Veterans Health Care System of the Ozarks serves veterans in 23 counties in Northwest Arkansas, southwest Missouri and eastern Oklahoma.

A Section on 09/25/2018

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