WaPo: How the VA failed to stop a pathologist who misdiagnosed 3000 cases (and killed hundreds)

Submitted to VT by the Washington Post (a VT media partner)

The Washington Post’s Federal Reporter Lisa Rein reports: By the time he and his wife Sara faced Veterans Affairs medical staff across a conference table in September, Kelly Copelin had lost 75 pounds and could swallow only small pieces of solid food. Radiation therapy had blistered his throat. This was the moment they would finally learn why their lives were so changed. Why when he went to the Fayetteville VA three years earlier with a severe earache, the biopsy came back negative — and he was given antibiotics instead of treatment for what was diagnosed 13 months later as late-stage neck and throat cancer. The pathologist who had misdiagnosed Copelin’s diseased tissue in 2015 was intoxicated, the hospital’s chief physician told the couple. He had failed to see the squamous cell carcinoma on the slide before him, the doctor said.

• On the Fayetteville campus, rated one of VA’s best, Levy’s supervisors failed to heed early warnings that he was endangering patients and then were slow to act, according to internal VA documents, court filings and interviews with 20 congressional officials, veterans and current and former VA employees.
• Pathology was a hard-to-recruit specialty, and one vital to serving a growing population of veterans retiring to the mountains at the junction of northwest Arkansas, eastern Oklahoma and southwest Missouri, known as the Ozarks. Levy was named chief of pa­thol­ogy and laboratory medicine services.
• Federal prosecutors charged Levy, 53, last week with three counts of involuntary manslaughter in the deaths of three veterans. VA officials now acknowledge that he botched diagnoses of at least 15 patients who later died and 15 others whose health was seriously harmed. The number of those affected, however, is much greater, and the full repercussions of Levy’s actions may not be known for years. VA officials say Levy made 3,000 errors or misdiagnoses dating to 2005.
• An unprecedented 18-month review completed this summer by a team of pathologists from other VA hospitals and affiliated medical schools uncovered a rate of misdiagnoses of nearly 10 percent, more than 10 times the normal frequency of mistakes by pathologists.
• In March 2016, Levy was intoxicated when he was called to the radiology department to assist with a biopsy. A VA-ordered test showed his blood alcohol level at 0.4, five times the legal limit in Arkansas of 0.08, a level that put him at risk of coma and death, prosecutors said. VA officials suspended Levy and reported his alcohol impairment to state medical boards — but gave him a second chance. He entered a three-month inpatient treatment program in Mississippi at taxpayer expense, officials said.
• After his firing, Levy relocated to Saba, a small island in the Dutch Caribbean, where he secured a position teaching pa­thol­ogy on the faculty of the local medical school, his lawyer said. At the time, he had active medical licenses in California and Florida. They were not revoked until this spring. He returned to Fayetteville in July, weeks before his arrest. Meanwhile, some former patients are still waiting anxiously to learn what Levy’s misdiagnoses mean for them.

FULL PIECE: https://wapo.st/32deeCb