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Jason Simcakoski: Thirteen Prescribed Drugs in Twenty-Four Hours

Jason Simcakoski did the thing the system says a veteran in trouble is supposed to do, twice over. As a patient, he checked himself into the Tomah VA's psychiatric unit on August 10, 2014, asking for help with anxiety, post-traumatic stress, and drug misuse. As a witness, in 2013 he had already called the Tomah VA's own administrators, the Tomah police, and the FBI's La Crosse office to report that patients at that hospital were selling their prescription pain medications — reports his widow later testified disappeared. On August 30, 2014, in the hospital's short-stay mental health unit, he was found unresponsive in his bed. He had taken thirteen prescribed medications in twenty-four hours, several of them known to suppress breathing, including a new one started the day before his death that neither of his two psychiatrists had explained to him or to his family. The autopsy finding was mixed drug toxicity. He was thirty-five, a former Marine corporal, the father of a young daughter. This page is the record of his service, of what the Tomah VA did and did not do while he was its patient, of what its watchdog did and did not do for the three years before that, and of the law his family carried into the United States Code under his name.

The service and the promise

Jason Simcakoski served in the United States Marine Corps from 1998 until his honorable discharge in 2002, according to the VA Office of Inspector General’s inspection of his death. He reached the rank of corporal. He was a Wisconsin veteran, of Stevens Point, married to Heather Simcakoski — herself a Marine Corps veteran, according to reporting on the family’s later work — and the father of their daughter, Anaya.

Senator Ron Johnson’s office, introducing legislation years later to rename the Tomah medical center for him, recorded the injury that organized the rest of his life: during his service, Simcakoski sustained a significant head injury that required prolonged treatment at the Tomah VA; his parents, Marvin and Linda Simcakoski, said in 2018 that he was overprescribed opioids at Tomah following a skull injury. The OIG’s account of his VA years matters here, because the institution’s later attempt to shift responsibility for his death onto him runs against its own record. He established VA care in 2003. In 2005 he sought help for an addiction to oxycodone — a drug he told providers he had obtained from a friend; the OIG noted that no VA provider ever prescribed him oxycodone or any other Schedule II opioid analgesic. He was treated for addiction at a non-VA clinic through 2007 and again in 2010. His diagnoses, as the OIG listed them, were posttraumatic stress disorder, bipolar I disorder, generalized anxiety disorder, attention deficit/hyperactivity disorder, panic disorder, opioid dependence, and alcohol and benzodiazepine abuse — addiction layered on mental illness, the exact profile for whom sedating drugs in combination are most dangerous.

The facility was the Tomah VA Medical Center in Tomah, Wisconsin. Dr. David Houlihan, a psychiatrist, was hired there in 2002 and promoted to chief of staff in 2004. The Senate Homeland Security and Governmental Affairs Committee’s investigation later established two facts about that hiring and promotion. First, VA regional leadership knew, both times, of Iowa medical-board charges that Houlihan had inappropriate professional boundaries with a patient; VA did not formally address them until 2009, when regional leadership deemed the issue “resolved.” Second, Tomah employees were calling Houlihan the “Candy Man” from at least 2004, and veterans called the facility “Candy Land.” The numbers behind the nicknames were documented by the Center for Investigative Reporting (CIR), whose January 2015 investigation broke the story open: oxycodone pills dispensed at Tomah rose from 50,000 in 2004 to 712,000 in 2012 — a fourteen-fold increase — and opiate prescriptions overall more than quintupled even as the number of veterans seeking care declined. VA’s own internal review, completed in March 2015, found Tomah patients two and a half times more likely than the national average to receive high doses of opiates.

The promise, in this case, was not abstract: a veteran inside a VA psychiatric unit, under observation, taking only what its doctors hand him, is owed drugs that will not combine to stop his breathing, a warning about what a new drug does alongside the old ones, and an immediate, equipped response if he is found unresponsive. The record that follows is the record of those three obligations, and of what happened when all three failed on the same afternoon.

What happened

The warnings came first, from inside the building as well as outside it. On November 11, 2007, a Tomah patient, Kraig Ferrington, died of a “poly medication overdose” less than twenty-four hours after his discharge; consultants and peer reviews convened after his death flagged the facility’s medication management, one VA consultant citing “general concern regarding the number of medications [Mr. Ferrington] was on, and the potential interactions among them.” In 2009, the president of the Tomah employees’ union local outlined the problem in a memo USA Today later reported was marked hand-delivered to members of Wisconsin’s congressional delegation, who said they had no recollection of receiving it; the Senate committee found the VA OIG received the union’s information in 2009 and apparently ignored it. That same year, pharmacist Noelle Johnson was fired after, by her later testimony, refusing to fill prescriptions she believed unsafe, and staff psychologist Dr. Christopher Kirkpatrick, who had raised concerns about over-medication, was fired and died by suicide the day of his termination. The committee’s first finding states the span plainly: from at least 2007 to 2015, serious problems of over-prescription and abuse of authority existed at the Tomah VAMC, resulting in at least two veterans’ deaths and the suicide of a staff psychologist.

The watchdog’s timeline is the center of this case, and its dates are not contested. In March 2011, the VA OIG hotline received a complaint about prescribing at Tomah; the OIG referred it to the VA’s regional network director, accepted the response, and closed it. In August 2011, a second, anonymous complaint arrived, and this time the OIG opened a health care inspection, which ran from October 2011 to March 2014 and examined thirty-two allegations. It found that two Tomah providers — Houlihan and nurse practitioner Deborah Frasher — prescribed at “considerable variance” with most opioid prescribers in the region, raising “potentially serious concerns.” It did not substantiate the allegations. In March 2014, the OIG administratively closed the inspection — an eleven-page document — without making it public. Assistant Inspector General John Daigh later defended the decision on the record: the data, he said, did not support the allegations. The Senate committee, reviewing the same work two years later, found that the inspection team had originally intended to publish, that leadership overrode it, that the team never examined how opioids interact with other medication, that it ignored pharmacy consultants who warned the facility could lose its controlled-substance license, and that its substantiation standard was so unclear as to be arbitrary. Its conclusion is the sentence this case is filed under: “Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility.”

Jason Simcakoski spent the last year of his life inside that unacted-upon record, and he contributed to it. In 2013, the Senate committee verified, he called Tomah VA administrators, the Tomah police, and the FBI’s field office in La Crosse to report patients diverting and selling their prescribed pain medication. His widow testified that some patients were making so much at it they had saved a down payment on a house, and asked the question the committee later put to the FBI Director in writing: who was responsible for Jason’s reports, where are they, and why did no one do anything? The FBI told the committee it had no record of its contacts with him.

He was admitted to Tomah’s acute psychiatric unit on August 10, 2014, having checked himself in — the accounts describe the presenting problems, in varying words, as anxiety, post-traumatic stress, and chronic drug misuse — and was transferred to the short-stay unit. In his final days, by the OIG’s account, staff psychiatrists added new medications to a list already long. His family testified that tramadol, a powerful opioid painkiller, was added just days before he died, although, they said, he did not have the chronic-pain condition for which opioids are usually prescribed. On the day before his death, the OIG found, his psychiatrists began buprenorphine/naloxone — Suboxone, a drug approved for treating opioid addiction — for off-label purposes the report described as treating symptoms such as anxiety, pain, and migraine headache. Neither psychiatrist obtained his informed consent, verbal or written, for that drug: that is the OIG’s finding, from the health record and the psychiatrists’ own accounts. The doctors also failed, the OIG found, to advise him or his family of the risks of the new prescriptions or their off-label use. His father testified to what raising a concern looked like from the family’s side of the desk: when Marvin Simcakoski questioned the physician treating his son in those final days, “She said I might know how to pound nails and build houses, but I don’t know anything about taking care of my son.” On August 27, 2014, Jason texted his father from the ward: “I slept horrible last night. I tossed and turned sweating … then I just stayed up. I couldn’t take it. I’m worse now than before I came in.” On the morning of August 30, his family visited; he complained of a headache and was given an analgesic to rest. His widow recalled: “I assumed he would sleep and wake up and it would be fine. He was an inpatient. Never in a million years would I think he could die.” His father said he was so sedated he could barely speak. That afternoon, a staff member found him unresponsive. The family’s later lawsuit put the discovery at 2:45 p.m. and alleged CPR was not started for about ten minutes and emergency responders did not arrive for twenty. The OIG’s findings on the response are separate from the lawsuit’s allegations and damning without them: staff did not immediately assess the patient and determine the need for CPR; they did not use the in-room emergency call system; they did not use the defibrillator to determine cardiac activity; when facility firefighters arrived, staff stopped CPR expecting the firefighters to take over, although firefighters are not designated first-line emergency responders; and the unit did not have on hand medications that could have countered an overdose. He died that day. The University of Wisconsin Hospital and Clinics identified the cause of death as mixed drug toxicity. He had taken thirteen prescribed medications in twenty-four hours, including several that cause respiratory depression. When OIG investigators asked, the prescribing doctors suggested that Simcakoski, who had privileges to leave the hospital for a few hours at a time, had probably obtained extra quantities of his medications on his own. The investigators’ answer is in the report: nearly all the drugs in his system could cause sedation, and his record confirmed all of them were prescribed by providers at the facility.

Five months later, the closed inspection and the death became public together. Ryan Honl, a combat veteran and West Point graduate who had started work as a secretary at Tomah two weeks before Simcakoski’s death, began lodging whistleblower complaints in September 2014; after leaving the facility in October, he carried the nonpublic OIG report to the Center for Investigative Reporting, which published on January 8, 2015. Under congressional pressure, the OIG published its Tomah inspection on February 6, 2015. The same weeks brought a second Tomah death into the record: Thomas Baer, seventy-four, who waited over two hours at the Tomah urgent care clinic on January 12, 2015 with stroke symptoms, on a day the facility’s only CT scanner was down, and died two days later. His daughter, Candice Delis, would testify beside the Simcakoskis: “My dad was entitled to competent care and the VA had a duty to provide it.”

What the institution did afterward

The institution answered in layers, and the layers did not agree with each other. VA’s own internal investigation of Tomah, completed in about three months in early 2015, found what the OIG’s nearly three-year inspection had not: as the Senate committee put it, “In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years.” On August 6, 2015, the OIG published its separate inspection of Simcakoski’s death itself — Report No. 15-02131-471, “Unexpected Death of a Patient During Treatment With Multiple Medications” — and that document does not equivocate. It concluded that mixed drug toxicity caused the death and that contributing factors included failures of teamwork, of informed consent, of the emergency response, and of access to equipment. Tomah’s statement, carried in the Federal Practitioner summary, called it “the tragic, avoidable death of this veteran.” One of the two psychiatrists was terminated; the second faced administrative proceedings. His widow: “I feel some comfort knowing they have admitted they failed Jason. It doesn’t bring him back, but I know it’s a step closer to getting justice for him.” Senator Tammy Baldwin, who had requested the investigation, stated: “This report confirms that the Tomah VA physicians entrusted with Jason’s care failed to keep their promise to a Wisconsin Marine and his family.”

Congress took the case into the town where it happened. On March 30, 2015, the Senate Homeland Security and Governmental Affairs Committee and the House Committee on Veterans’ Affairs held a joint field hearing in Tomah. Heather and Marvin Simcakoski testified, alongside Honl, Noelle Johnson, and Candice Delis, and opposite the officials whose offices had closed the case: Assistant Inspector General John Daigh, senior OIG physician Alan Mallinger, Interim Under Secretary for Health Carolyn Clancy, and Tomah director Mario DeSanctis. The committee’s investigation ran sixteen months, took transcribed interviews of more than twenty VA and VA OIG employees totaling some eighty-two hours, reviewed tens of thousands of pages, and subpoenaed the OIG for documents the committee reported the OIG knowingly withheld. On May 31, 2016, Chairman Ron Johnson released the result in Tomah: a 359-page majority staff report, “Systemic Failures at the Tomah VA,” whose core judgment was that the tragedies “were preventable and were the result of systemic executive branch failures.” Deputy Secretary Sloan Gibson, testifying at the hearing that accompanied the release, did not contest the ownership: “This is a leadership failure. … At the end of the day, we own this. VA leadership owns this. We had ample opportunities over the years to fix this.”

The political record has a contested edge, and this page keeps it attributed rather than resolved. Reporting by the Associated Press and USA Today established that Senator Baldwin’s office received a copy of the OIG’s Tomah inspection in August 2014 — by the AP’s account, the day before Simcakoski died — and did not act publicly on it until January 2015, after CIR published. Baldwin acknowledged mistakes; a review she commissioned from attorney Marc Elias found her constituent services team had not passed concerns to senior staff. She cut her chief of staff’s pay, demoted her state director, and fired an aide. Her opponents made Tomah a campaign issue for years; her answer, also on the record, was the legislation below, built with the family, who in 2018 appeared in her defense to say she had “literally been there with us every step of the way for three years.”

Personnel accountability came in pieces. Houlihan was fired by VA in November 2015, his clinical privileges terminated. DeSanctis was removed as director in September 2015 and fired that year; in 2017, USA Today reported, he fought the dismissal and settled on terms that let him resign, with $163,000 paid to him and his attorney — an outcome Heather Simcakoski called “really disappointing.” The longest thread was Houlihan’s license. Wisconsin’s Medical Examining Board found probable cause that he had been unprofessional and negligent in Simcakoski’s care and in his overall practice; the Department of Safety and Professional Services found, as Senator Johnson’s statement on the order summarized it, that he had failed to provide appropriate medical care to at least twenty-two veterans over several years. On January 10, 2017, Houlihan signed an agreement surrendering his Wisconsin license permanently, never to reapply; the board accepted it on January 18, 2017, closing the psychiatry practice he had opened in La Crosse after his firing, with the order entered in a national physician database. No criminal charge arising from Simcakoski’s death appears in the public record — against Houlihan, against the two psychiatrists, or against anyone else.

The statute is the largest thing the institution produced, and it carries his full name. In June 2015, Senators Baldwin and Shelley Moore Capito introduced the Jason Simcakoski Memorial Opioid Safety Act; in the House, Representative Gus Bilirakis’s parallel measure was the PROMISE Act — the Promoting Responsible Opioid Management and Incorporating Scientific Expertise Act. The two converged, and on July 22, 2016, President Obama signed the Comprehensive Addiction and Recovery Act, Public Law 114-198, whose Title IX is the Jason Simcakoski Memorial and PROMISE Act — “Jason’s Law.” As enacted, it requires VA and the Department of Defense to update their clinical practice guidelines for opioid therapy, with stricter standards against dangerous combinations and against prescribing opioids to patients with mental health conditions; requires enhanced safe-prescribing training for VA prescribers; requires pain management teams at VA facilities for non-cancer pain; requires facilities to stock overdose-reversal medication such as naloxone — the drug class whose absence the OIG noted in his room’s response; strengthens patient advocacy, creating an Office of Patient Advocacy whose advocates do not answer to the facility chain of command — the provision Baldwin said mattered most to the Simcakoskis, because “In Jason’s case, he and his family questioned the treatment. But nevertheless, the patient advocate answered to the prescribing physician and the hospital chief of staff. That’s not independence”; requires VA providers to share data with state prescription monitoring programs; mandates use of the Opioid Therapy Risk Report tool across VA; and holds the system to account through GAO review and VA reports to Congress. Congress then funded it: the fiscal 2018 omnibus carried $385 million for VA opioid treatment and prevention, including more than $55 million to continue implementation of Jason’s Law.

The civil case closed the family’s own account. In August 2016, Heather Simcakoski filed a federal wrongful-death and medical-malpractice suit in Madison. In October 2017, the government settled for $2.3 million: about $1.65 million to Heather and Anaya, another $659,000 into annuities for them, and the remainder to fees and expenses. The settlement stated that it was not to be construed as an admission of fault and that it avoided the expense and risk of further litigation. The admission, such as it was, had already been made in the other record — the OIG’s word “avoidable,” and the Deputy Secretary’s “we own this.”

Where it stands now

Jason’s Law is permanent law, and its implementation is the open item. The requirement his case wrote most directly — a pain management team at every VA facility overseeing non-cancer pain therapy — has never reached full compliance. Senators writing to the VA Secretary, citing the Inspector General’s audits, put the figures in a letter the department has not answered in public as of this writing: in September 2019, 32 percent of Veterans Health Administration facilities were not in full compliance with the requirement; by October 2024, the share had risen to 33 percent, even as outright noncompliance fell from 4 percent to 1 percent and partial compliance grew. The senators asked VA for a plan to bring every facility to full compliance. The gap is the same gap, in administrative form, that runs through the original record: a standard on paper, unevenly present in the building where a veteran is actually lying.

Tomah itself produced a second scandal a decade later, and this page records it because it is the same institution answering the same question. Beginning in 2022, KARE 11 reported that a Tomah neurologist, Dr. Mary Jo Lanska, had systematically misdiagnosed veterans’ neurological conditions in compensation-and-pension exams; VA reviewed 941 of her exams, found 649 veterans may have been negatively impacted, fired her, and offered the 649 new examinations with benefits backdated to their original claims. KARE 11’s documentary on that case, “Broken Promises,” is in the video wall below. And in September 2026, Senator Baldwin wrote again to the VA Secretary and the Inspector General — her letter records that a Tomah nurse faced criminal charges over an August 2025 incident in which oxygen was allegedly withheld from a hospice patient who later died — demanding an investigation of staff claims of serious failures in care, staffing, hospice coverage, and leadership’s response to employees who raise concerns. “The Tomah VA and the veterans it serves have spent years working to rectify and recover from the serious failures uncovered at the facility more than a decade ago,” she wrote. “We cannot allow serious patient safety or management problems to take root again.”

What endures under his name is not only the statute. After his death the family founded the Jason Simcakoski Foundation — the Simmy Foundation — to increase access to quality mental health care for veterans and their families and to promote effective, non-pharmaceutical alternatives to the treatment that killed him. Its most visible work is on the grounds of the facility itself. The nine-hole golf course at the Tomah VA, where Marvin Simcakoski had played with his son during his treatment — “Near the end of his life some of our closest moments, as father and son, were here on this golf course” — closed in 2014, the year of Jason’s death, when federal funds for VA golf courses were barred. The foundation, the Disabled American Veterans, and the city of Tomah restored it, largely by volunteer labor, and on June 1, 2022, it reopened as the Jason Simcakoski Memorial Golf Course, with Secretary of Veterans Affairs Denis McDonough playing the reopening round beside Marvin Simcakoski. In January 2024, the entire Wisconsin congressional delegation, led by Senator Baldwin and Representative Derrick Van Orden, introduced legislation to rename the Tomah VA Medical Center itself for him: “Now, every veteran who walks through the doors at Tomah VA will remember Jason’s service and know the difference he made for his fellow veterans,” Marvin Simcakoski said. No enactment of the renaming has been located in the record as of this writing; the facility still operates under its geographic name. The fight this series grades complete — statute enacted, settlement paid, license surrendered — is complete in those particulars. The standing items are the ones his family chose: full compliance with the law that bears his name, in every building, and a watchdog that publishes what it finds while publication can still change the outcome. If you or a veteran you know is in crisis, the Veterans Crisis Line is available around the clock: dial 988 and press 1, or text 838255.

The ledger

What has been done

What has not been done

What is being sought

The record, on video

The Tomah record was made in hearing rooms as much as in reports. Below: Senator Shelley Moore Capito, co-sponsor of the Senate bill, making the case for the Jason Simcakoski Memorial Opioid Safety Act on the Senate floor; and the Scripps Howard Awards film honoring KARE 11’s investigation of the second Tomah scandal — included because it is the same institution, a decade later, answering for the same kind of failure.

The Senate case for Jason's Law. Senator Shelley Moore Capito, who introduced the Jason Simcakoski Memorial Opioid Safety Act with Senator Baldwin, speaks on the Senate floor on behalf of the nation's veterans and the legislation written from his death. (U.S. Senator Shelley Moore Capito.)

Broken Promises. The Scripps Howard Awards film honoring KARE 11's investigation of the Tomah VA's second scandal: a neurologist's misdiagnosed compensation-and-pension exams, 941 cases reviewed, 649 veterans offered new exams. The same facility, ten years on. (Scripps Howard Foundation.)

Sources

Part of Betrayed, Not Forgotten — this site's accounting for the service members and veterans their own institutions failed. Videos are embedded from their publishers; nothing here is re-hosted.