Geraldine Dodson's body was found in a seated position on the living-room floor, near a bowl of uneaten cereal.
On that morning--July 25, 1990--family members discovered several empty bottles of prescription medication tucked away in various corners of Dodson's west Phoenix mobile home.
Later that day, the Maricopa County Medical Examiner classified the 53-year-old grandmother's death as accidental, the result of a drug overdose. Her blood was laced with high levels of chemicals found in sleeping pills, painkillers and muscle relaxants.
The drugs had been prescribed by Dr. Willard Hunter, a Phoenix orthopedic surgeon whom Dodson visited every three weeks for what she said was terrible back and neck pain.
Dodson also apparently had consumed some Valium; Hunter had prescribed that drug, along with painkillers, for Dodson's alcoholic husband, Bill, who claimed that he, too, suffered from excruciating back problems.
When Glendale police contacted Hunter by telephone, the doctor said he'd just seen Geraldine Dodson on July 17, and she appeared fine. He had refilled her prescriptions and sent her on her way.
Seeing no need for further investigation, police closed the case.
About two years later, Jeff Sykes, a 32-year-old drug addict, also died of a drug overdose. He died the day after he refilled a round of potent prescriptions from Dr. Hunter.
Sykes' corpse was found on the front lawn of his downtown apartment, dressed in a black-and-white cowboy shirt, jeans, gym shoes. At first, neighbors who discovered the body thought Sykes had simply passed out, again, from those pills he took all the time.
After a cursory investigation, Phoenix police did not refer the Sykes case to prosecutors for review for possible criminal prosecution. Instead, they forwarded the matter to the Arizona Board of Medical Examiners, colloquially known as Bomex.
At the time, the state board that regulates medical doctors already had information on the death of Geraldine Dodson, as well as results of its own investigation of Hunter's office records--an investigation that revealed a pattern of misprescribing addictive drugs.
But the board did not revoke Hunter's license.
In fact, he is still practicing medicine in Phoenix.
Family members of Sykes and Dodson feel let down by Bomex, which had knowledge of Hunter's misprescribing of drugs for years, yet failed to act swiftly enough to prevent the doctor from writing prescriptions that led to two deaths.
The families also live with what they see as another fundamental injustice. Bomex did not refer either case to federal or state authorities for possible criminal prosecution--even though doctors in similar situations have been prosecuted in other states, and even though Bomex would eventually determine that Hunter's "unprofessional conduct" violated state law and was, indeed, negligent.
Criminal cases against doctors are difficult to prosecute, but Arizona prosecutors say they would still like the opportunity to know about suspicious deaths. "If someone dies, and there is a question about how he dies, wewould hope that would be advanced to a prosecutorial office for review," says Bill FitzGerald, spokesman for the Maricopa County Attorney's Office.
But there is no law or Bomex policy mandating referral of cases involving patient deaths for possible criminal prosecution, and the state board does not consider turning over such cases as part of its mission.
If the families want redress beyond the discipline Bomex might mete out, says Richard Zonis, the board chairman, then it's up to them to get it.
"I think it is assumed in a high-profile case such as this, where someone dies as the result of a doctor's action, that the family has already obtained legal advice and has probably pursued all avenues available," he says.
In the state of Georgia, however, the Composite State Board of Medical Examiners takes an entirely different view of potentially criminal conduct by doctors. That board routinely refers "egregiously" misprescribing physicians to either state or federal prosecutors, who have sought and obtained criminal convictions, says Andrew Watry, executive director of the Georgia board. And prosecutors in other states have also charged doctors with manslaughter or reckless endangerment when deaths seemed to flow directly from medical negligence.
Such prosecutions also prevent doctors from practicing medicine. The Sykes and Dodson families are perplexed and insulted that, despite two deaths and the state board's own ruling that Hunter was negligent, the doctor still has his medical license. Hunter maintains that license under a plea bargain approved by the very board that said he was negligent in the first place.
Hunter did not respond to repeated requests for interviews. Files at Bomex and other public records, however, show that the board has had more than adequate reason totake strong action against the doctor.
For at least a decade, Bomex has used what it calls "progressive discipline" on doctors accused of wrongdoing. Under that policy, Bomex first issues nondisciplinary warning letters to errant doctors, then follows up with more serious actions.
But in Hunter's case, the board was inconsistent. His file contains four warning letters, the result of numerous complaints made to the board during the doctor's 30 years of practice. (The complaints involve allegations of misprescribing, as well as charges of botched orthopedic surgeries.) Hunter was also put on probation, taken off probation, warned that if he made another mistake he'd lose his license, then put on probation again. Today, he is still allowed to practice medicine, on a limited basis.
He is also licensed in Utah, where he can practice with no restrictions at all.
"It is obviously very enticing to pick out one case that went bad," says Zonis, who at one point threatened to push for the revocation of Hunter's license but later agreed to the 1995 plea bargain that allowed the doctor to continue practicing medicine. "Everyone looks back, has remorse and says we should have disciplined the doctor sooner.
"But for every Dr. Hunter, there are probably 20 to 30 other physicians who had the same problem [misprescribing drugs] and who the board never hears from again."
The death of Geraldine Dodson could not have been more wrenching for her daughter, who asked that her real name be concealed in this article to protect her school-age children who do not know their grandmother was a drug addict.
The daughter, "Michelle," now 37, had spent much of her life trying to wean her mother from prescription drugs. She failed in the end. And she blames Dr. Hunter.
Off drugs, Dodson was energetic and entertaining. On drugs, she might fall into such a stupor that she could no longer chew or swallow. Or she might be so crazed that she'd threaten to kill her children.
"It was like a roller coaster with Mom; you never knew what to expect," Michelle says.
Geraldine Dodson had been hooked on prescription drugs off and on since 1970, when Michelle was 11 years old. As a child, Michelle would sometimes run, along with her two brothers, to a neighbor's house for safety. After she grew up, Michelle married that same neighbor's son. She had kids of her own. She's tried to do the things her own mother couldn't do, like volunteer in the school, chauffeur, be available.
Michelle knew what it was like to have a mother who wasn't available.
Dodson's prescription-drug addiction began when she was hired as a secretary for a doctor. Her boss prescribed Valium for her nerves, and Dodson liked it. Soon, she was phoning in her own prescriptions. And writing them.
Velma Eichenlaub, Dodson's sister, recalls that she and other members of the family once confronted Dodson about several forged prescriptions they discovered rolled up in an empty pill bottle. Those aren't mine, Dodson told her sister. Why would I write fake prescriptions?
The police got ahold of another set of bogus scripts, however, and Dodson was convicted in 1974 of forging prescriptions; she was put on probation.
Dodson met her second husband, Bill, at a Phoenix rehab center for drug and alcohol abusers. (After Geraldine's death, Bill moved to Black Canyon City, where he died, the family says, of acute alcoholism.)
She must have known that Michelle, although an adult, still hungered for a normal mother. In 1980, when Michelle was 21, Dodson finally mustered the strength to check herself into St. Luke's Behavioral Health Center to clean up. It cost her $10,000--her life savings.
She remained clean for five years, got a job as an apartment manager. She was married to Bill, in touch with her three adult children, happy.
Then, in 1985, she fell off a ladder while hanging some curtains in a vacant apartment and injured her neck.
She went to Dr. Hunter after the neck injury. Fix my neck, Michelle remembers Dodson telling Hunter, but don't let me get hooked on drugs again. Hunter assured both mother and daughter that the pills he would prescribe would not be addictive.
But pharmacy records show that Hunter prescribed Dodson more than $5,000 worth of Vicodin, Tylenol with codeine, Soma and Placidyl, each of which, according to the Physicians' Desk Reference, should be given with great care to patients with addictive tendencies.
After Dodson became readdicted, she slipped in and out of depression, which may explain why she attempted suicide just two months before she died. The suicide attempt was serious--she swallowed a cocktail of the same kinds of pills, all prescribed by Hunter, that eventually killed her.
Dodson's life was saved by doctors at Maryvale Samaritan Hospital, who diagnosed her as a severely depressed, suicidal drug addict. When Dodson was released five days later, she vowed to stay clean, to join a drug-rehab program.
Instead, she went back to Dr. Hunter.
And Hunter had been warned, says Michelle, not to give her mother more drugs.
After her mother's near-fatal drug overdose, Michelle says she telephoned Hunter's office manager and asked her to notify Hunter about her mother's condition.
Hunter himself noted in records that Dodson had been "hospitalized at Maryvale" for a possible drug reaction. He did not call the Maryvale doctors for a briefing on his patient's condition, however, and they are unsure whether they called Hunter. Hunter later testified that he did not know Dodson had a drug problem.
And he refilled Geraldine Dodson's prescriptions three more times before she died of the second overdose.
Michelle insists the second overdose was not a suicide attempt. There was no suicide note, she says, ignoring the fact that her mother left no note the first time.
"Things were getting better for Mom," she says stubbornly. Just the day before she died, Michelle says, Geraldine Dodson helped her daughter plan a family birthday party.
After her mother died, Michelle collected Dodson's pharmacy records. Michelle wanted to sue Hunter for medical malpractice, but was discouraged by an attorney. A jury, the lawyer explained, would side with Hunter. After all, Dodson was a suicidal drug addict.
For at least 15 years, in at least four reports, the Arizona auditor general has criticized Bomex, comprised mostly of doctors, for being too lax in disciplining physicians (see related story below). The state auditors have also repeatedly noted that Bomex can take years to investigate complaints. And once those complaints are investigated, they are not always investigated thoroughly.
In the case of Willard Hunter, public records show Bomex had ample warning that Hunter was misprescribing drugs long before Sykes and Dodson died.
In fact, just one month before Dodson died, Bomex had called Hunter in to discuss results of a cursory board survey of his practice that turned up evidence of misprescribing.
Hunter explained he saw 20 patients a day. Most needed pain medication. "I think I see a lot of patients nobody else wants," he said. "I think that my practice is such that my patients take more medicine than the average orthopedist's."
It was clear during that meeting that Willard Hunter had several patients who were addicts.
When explaining why he prescribed 14 daily doses of the potent and addictive painkiller Percocet to one patient (not Dodson), he said: "I think that on several occasions she told me that she lost them, flushed them down the toilet."
Other patients seemed to lose drugs regularly.
"Some people go to Swap and Shop, and their cars are broken into and their meds are stolen," Hunter explained. "Well, that's good for two or three times, but if that keeps happening, I have to quit giving them the medicine."
Instead of restricting Hunter's prescribing license, or taking away his medical license altogether, Bomex let Hunter off with a warning letter.
A month later, Geraldine Dodson died.
In April 1991, almost a year after Dodson's death, Bomex once again summoned Hunter. This time, the board asked him to explain why, in the face of a recent suicide attempt and hospitalization, Hunter refilled Dodson's prescriptions.
"I had been seeing the woman for five years and gave her the same medicine for five years," Hunter said. "She seemed to be a reliable person. ... I was trying to help her."
Asked if he addicted any patients in his 31 years of practice, Hunter said, "Maybe one or two."
Board members said the Dodson case was one of "medication abuse," but still did not discipline Hunter during that meeting. Instead, the board continued its investigation of his practice.
Investigators who reviewed more of the doctor's files turned up case after case of misprescribing--including the case of Jeff Sykes, who happened to be alive at the time.
A full 18 months after Dodson's death, Bomex put Hunter on three years' probation, limited his ability to prescribe some drugs under certain conditions and ordered him to take 80 hours of courses on prescribing and pain control.
Given Dodson's death, as well as numerous other documented cases of misprescribing, the punishment seems mild.
Even though he was on probation, Hunter was still allowed to prescribe the drugs that contributed to the death of Jeff Sykes.
"Dr. Hunter was a big part of my son's life for many years," says Laverne Pippett, Jeff Sykes' mother. "I visited his office on two different occasions and told Dr. Hunter not to give Jeff those drugs, but he didn't seem to listen."
She remembers explaining to the doctor that Jeff was a drug addict on a methadone-maintenance program. Pippett has no delusions about her dead son, her favorite son. He became addicted to practically every drug he tried--opiates, prescription drugs, cocaine. He'd served a few years in prison for drug-related crimes. If the physician continued prescribing drugs, Pippett feared, Jeff would never straighten out and would surely go back to prison.
Jeff was Pippett's most affectionate child, the one who took time to sit down with her on the couch after she'd worked all day cutting hair and giving manicures at the beauty shop, the one who'd tell her she still looked pretty.
Jeff got addicted early, Pippett says, in high school. He once told a drug counselor his father got him started.
Now and then, he talked to his mother about stopping and had enrolled in the methadone program in hopes of controlling his addiction. Counselors at the methadone clinic asked Dr. Hunter to wean Jeff from the prescription drugs, but, they said, the doctor did not cooperate.
It is true that Jeff was in some pain--he smashed his car into a tree in 1991 while on drugs--and Hunter had performed a series of operations on Jeff's back.
But the methadone alone might have been enough to help Jeff cope with the pain.
"I've been getting him off his medicine," Hunter said at a Bomex hearing shortly before Jeff died. "His wife left him and took his medicine, and I refilled that about a week ago, and I'm going to reduce him after that."
But Hunter did not get Jeff off his medicine.
In May 1992, a day after refilling yet another round of prescriptions from Dr. Hunter, Jeff died of a drug overdose.
The county medical examiner determined that Jeff had died of heart failure brought on by an accidental drug overdose. His blood contained toxic amounts of methadone, a small amount of cocaine, plus Placidyl and Xanax, two drugs prescribed by Hunter that do not mix with methadone.
Pippett was heartbroken, furious.
She informed her family doctor that she wanted to sue Hunter for medical negligence. The family doctor, who had recommended Hunter in the first place, persuaded her to forget a lawsuit.
At the time of his death, Jeff Sykes was being investigated by Phoenix police, who suspected him of selling the large quantities of prescription drugs he was getting from Hunter.
Upon learning of Sykes' death, police performed a cursory investigation. After the medical examiner ruled the death was accidental, police closed the case and sent the file over to Bomex "for adjudication" one month after Sykes died.
But Bomex did not tackle the Sykes death case until October 1995, three years after he died. And even then, the board had a strange way of taking care of a doctor whose misprescribing had helped end the lives of two patients.
After Sykes died, but before Bomex heard his case, the board agreed to end Hunter's three-year probation a year early because Hunter said he was facing terrible financial problems and had, after all, already completed his 80 hours of required classes on the proper way to prescribe drugs and control pain.
One Bomex board member, William Holsey, said Hunter's punishment had been "in keeping with the crime."
Then he went on to sympathize with Hunter. "Unfortunately," he said, "we have to deal with insurance companies, HMOs and whatnot. Since they all act upon what this board determines, one can be devastated by their actions, which apparently is what occurred in your case.
"I gather you have very little to fall back on other than the various [insurance] plans that you were in, which have now been taken away from you as a result of this action."
When Bomex finally reviewed the Sykes drug-overdose death, the board reinstated Hunter's probation. Hunter signed an agreement with the board rather than undergo a hearing during which his license might be revoked.
The plea bargain allowed Hunter to keep his state license to practice medicine, although he surrendered his federal license to prescribe addictive drugs. He also agreed not to assist in or perform surgeries unless he took a yearlong course in orthopedic surgery and met with the board for further approval.
Citing the Sykes and Dodson cases and others, the board determined that Hunter violated state law by failing to maintain adequate patient records, by practicing in a way that "is or might be harmful or dangerous to human health of the patient or the public" and by engaging in "conduct that the board determines is gross negligence, repeated negligence or negligence resulting in harm to or the death of a patient."
These days, Hunter lives in a bleak, east Mesa "gated community" of mobile homes. He practices solo, sharing an office with a Tempe chiropractor two days a week. Other days, he sees patients at a shabby-looking office at 1415 North Seventh Avenue.
Willard Hunter has said his habit of working hard has taken a toll on his personal life.
Hunter had five children by his first wife, Dora, who filed for divorce in 1974.
Dora said back then that Hunter threatened to split open her head with an ax. She said her husband could be violently, explosively angry.
Yet she lived with him for 22 years. She was married to Hunter when he was a medical student at the University of Tennessee, moved with him to Phoenix in 1956 for an internship at St. Joseph's Hospital. She celebrated with Hunter when the state gave him a license to practice medicine in 1957.
After Dora filed for divorce, the two fought over property for nearly two years before the divorce was finalized.
Dora got the family home, a 65-acre nut farm in Gilbert, which she promptly sold to the Roman Catholic Diocese of Phoenix. Hunter then sued Dora in a futile attempt to halt the sale of the farm. He wanted his exwife to sell the farm to his parents so he could gain control of it. She refused.
Then Dora seemed to disappear from Hunter's life.
His second wife, Debbie, 25 years younger than he, could not be found for comment. Last year, in a rambling interview with Bomex, Hunter indicated his second marriage, too, was headed for divorce.
He has often said he is a sick man, a serious diabetic who has endured almost as many surgeries as some of his patients.
He has claimed his financial ruin was brought on by Bomex. "Because of the restrictions placed on me, I lost all of my insurance referrals, and now I'm down to the point where I'm having some private patients, a few, and Medicare, and that's about it," Hunter said in 1994. "My income is such that I have lost about everything I had in 30 years. ... I can't even pay my malpractice insurance if I don't get more income. ... I don't have retirement; it's gone. I don't have a house. That's gone."
But it wasn't always that way. In the 1970s and 1980s, he lived in Paradise Valley and invested in Charolais cattle. He and Dora had a home in Guaymas, Mexico, a 65-acre farm in Gilbert, ranch land in eastern Arizona. As the years passed and Hunter began losing his fortune, he repeatedly went to court, seeking remedies to his many real estate and business disputes.
He didn't like to lose money.
He liked to make it.
He shared offices with several different doctors, including orthopedic surgeon Ranjit Bisla. While with Bisla, Hunter seemed to be making a great deal of money--he speculated in real estate, invested in Peterbilt trucks and Arabian horses.
Bisla "retired" after being disciplined by Bomex in 1989 for performing unnecessary surgeries.
Hunter once observed that he was a pretty good doctor, had performed a lot of important operations during his decadeslong orthopedic-surgery practice in Phoenix. "I was the first one to do anterior cervical disk incision with a fusion [a back operation] in this state," he said. "I was the first to do leg lengthening. I was the first one to use internal fixation of the spine in 1961. I was the first one to do congenital hip surgery."
He was also one of the first in Phoenix to be slapped with a major medical malpractice case in connection with a highly controversial experimental treatment for back pain called "chymopapain injection."
The victim, Katherine Gaston, alleged that Hunter used the wrong-length needle for the procedure, piercing her bowel as well as her spinal column and causing a crippling bacterial infection of her spine and brain. As a result, she said, she lost control of her bodily functions and ultimately became a paraplegic.
Gaston sued Hunter, the company that manufactured the chymopapain and St.Luke's Hospital for the 1970 operation.
Hunter, the hospital and the drug company all denied negligence, and Gaston lost her case in Superior Court in part because the judge would not allow her expert witness to testify.
Gaston appealed the case, won a new trial, and was awarded a $1.75 million settlement by a Phoenix jury in 1980. (By this time, the hospital and drug company had been dismissed from the suit.)
Neither Gaston nor her lawyers could be located for comment.
In a way, the case united Valley doctors, who began holding meetings on how to avoid being named in medical malpractice suits.
Hunter himself has been named in a relatively few malpractice suits--a total of 13 in state court, all of which allege negligent orthopedic surgery on adults and children, or careless surgical aftercare.
In each case, Hunter denied negligence or, more recently, simply failed to respond to the complaint.
Nearly half of the lawsuits were filed in the past five years.
Hunter won only one of these recent suits, filed by a woman who represented herself in court. She claimed Hunter's postsurgical care caused her to develop a blood clot in her lung because he failed to prescribe critical anticlotting medication. Her case was brought up recently at Bomex, prompting one doctor to comment that he worried about Hunter's "mental health."
Two of the recent suits allege that Hunter operated on the wrong limb. In one instance, Hunter admitted operating on the wrong ankle of a 12-year-old Tucson boy at Phoenix Children's Hospital. "It happens," Hunter later said. The parents, who live in Tucson and could not be located for comment, settled out of court.
In a pending case, Hunter allegedly operated on the wrong knee. His patient, Margaret Trapp, said Hunter made a joke out of it. She remembers him telling her: "I thought I was doing you a favor."
Officials at the Arizona Board of Medical Examiners feel they have appropriately disciplined Willard Hunter. He can no longer perform orthopedic surgery. He can no longer prescribe the drugs that helped kill two people.
They have protected the public, they say, from any dangers the doctor may have previously posed. Even though Hunter may still practice other forms of medicine--pediatrics, for instance--they see no reason to revoke his license.
And they see no reason to refer the overdose cases to the Maricopa County Attorney's Office, or any other prosecutorial office, for review for possible criminal prosecution.
There is no evidence in the public record that Hunter has blamed himself for any part of his many personal or professional troubles. He seems not to understand the role he played in the deaths of Jeff Sykes or Geraldine Dodson.
He seems, instead, to blame the victims.
"Most of the people [patients] I got, I kept on drugs because they needed it," he explained in 1994. "But most of the ones that I got were already on drugs, put on, I believe, almost 100 percent by someone else. But I kept giving it to them.
"I've learned that even though you're a feeling, caring person, that doesn't count, because patients use you."
But that type of manipulation, the families of Jeff Sykes and Geraldine Dodson say, is exactly what they warned Hunter about.
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If only he'd listened.
Nearly six years after Geraldine Dodson's death, the family finally pooled enough money to buy a headstone for her grave. It was ordered last month.
Laverne Pippett held her son's funeral at North Phoenix Baptist Church and gave him a proper burial. But that doesn't take away the emptiness she still feels.
On the day Jeff Sykes died, Pippett found in his apartment the bottles of painkillers and tranquilizers and sleeping pills Hunter had prescribed the day before.
For a reason she still can't explain, Pippett put the bottles in her car, took them to her house. She keeps them even now, locked in a cabinet.