Like almost any doctor would, Dr. Verda Hunter trusted that the pharmacist who provided her patients’ chemotherapy drugs would do his job well and would do nothing to harm the patients she was treating. But she was wrong.

The first clue was that cancer patients, like 70-year-old Pat Withers, were not experiencing side effects. Pat initially underwent surgery to remove a malignant tumor attached to her uterus, and then she started chemotherapy at the Research Medical Center in Kansas City, Missouri.

The drug should have caused some fatigue and resulted in hair loss, but weeks into treatment, Pat found that she still felt strong and hadn’t lost a single hair. She chalked it up to the grace of God and moved on. However, in a follow-up scan, she learned that her body was not responding to the drug and that the cancer had spread to her colon and liver.

Luckily, when Eli Lilly Pharmaceutical Company senior executive sales specialist Darryl Ashley showed up on the scene, he realized Dr. Hunter’s patients’ lack of symptoms was more than just a happy coincidence and began to look into the problem.

“When I talked to Dr. Hunter’s staff, they conveyed to me that they weren’t seeing the hair loss with the Taxol regiment and the nausea and vomiting with the Gemzar regimen…. that was troubling to me,” Ashley says. “And so that got me to thinking, ‘I wonder if these patients were getting the full dose of their chemotherapy.’”

Ashley asked where the office was receiving its medications from and was told that pharmacist Robert Courtney, owner of the Research Medical Tower Pharmacy, was responsible for preparing the drugs directly before they were administered to patients.

“[Courtney] would physically mix the compounds that were needed for each of the treatments for Dr. Hunter’s patients…. She trusted the pharmacist because they’re one of the most trusted professions in the world,” says FBI Supervisory Special Agent Judy Lewis-Arnold.

Ashley then tracked down a utilization report that showed that the amount of drugs Courtney was buying was far less than the amount of drugs he was selling to doctors. Courtney was also selling Gemzar for $20 less than the Eli Lilly price.

“That did not make any sense, because that meant that he was losing $200 to $300 per patient by providing them [a] drug,” says Ashley.

This evidence was enough to make Ashley suspect that Courtney was diluting his products, so he shared his concerns with Dr. Hunter, who sent a sample of one of the drugs to the lab for testing.

The results came back worse than anyone expected. The drug sample was only 30 percent as potent as it should have been.

Of course, Dr. Hunter immediately stopped buying medications from Courtney and switched to another pharmacy. Then she trained her staff to do the compounding themselves. She also contacted the FBI, which partnered with the FDA to investigate the matter.

A total of seven samples were submitted to the FDA for investigation, and they were all found to contain only 17 to 39 percent of the medication they were supposed to have.

A search warrant was issued for Courtney’s pharmacy, and Courtney admitted to his crimes while speaking to investigators. He was found to have made himself an extra $19 million dollars by diluting 98,000 doses of the drugs.

“This wasn’t just a typical prescription that a pharmacist was shorting to make a profit. This was actually affecting people’s lives,” says FDA investigator Stephen Holt. “They might as well have been being treated with a saline solution. There was no therapeutic benefit that was being had by the patient.”

The Research Medical Tower Pharmacy was immediately shut down, and Courtney was charged with one count of adulteration and misbranding. He turned himself in to the FBI, pled guilty, and was sentenced to 30 years in prison. The money he made from his crimes was seized and distributed to the patients who had been given diluted medications.

Meanwhile, all patients who were getting medications from Courtney’s pharmacy were directed to begin getting their prescriptions directly from the hospital.

“From the moment my mom got her treatments at a different location actually in the hospital, everything changed for her physically. Within a few days, she began to lose her hair. She did feel nausea, and she had never felt any of those things before,” says Pat Withers’s son, Clayton Withers.

All the same, Pat passed away a few months later. We can only wonder if she might still be here if she’d been getting the proper medication from the start.

“The end of my mom’s life was incredibly peaceful,” Clayton says. “My mom actually modeled what forgiveness looks like when you’re the victim, even in the face of a terrible injustice done to her.”