The family of a former Marine who died at the Tomah Veterans Affairs Medical Center in 2014 from a mixture of drugs that included opioids filed a wrongful death lawsuit Monday against the federal government, writing that despite accepting responsibility for his death, the VA has done nothing to act on a claim filed by the family nearly a year ago.

Jason Simcakoski, 35, died on Aug. 30, 2014, at the Short Stay Mental Health Recovery Unit in the Tomah VA’s Community Living Center, where he was getting treatment for mental health-related problems, according to the lawsuit, filed by his wife, Heather Simcakoski, in U.S. District Court in Madison.

Simcakoski’s death led to the firing of the Tomah VA’s chief of staff, Dr. David Houlihan. The medical center’s director also was reassigned to another job away from Tomah.

According to the lawsuit, VA representatives repeatedly told Simcakoski’s family that the VA intended to take full responsibility for his death.

The lawsuit quotes the acting director of the Tomah VA telling reporters a year ago, “We accept responsibility for any action or inaction that contributed to this man’s death.”

“The VA has failed to follow its words with deeds,” according to the lawsuit, which seeks unspecified compensation for alleged negligence by the VA, along with other costs.

The Tomah VA has come under fire after an Inspector General’s report, not released until after Simcakoski’s death, found that opioid painkillers were being overprescribed by doctors at the medical facility, which some called “Candy Land.”

Simcakoski, of Stevens Point, who was honorably discharged from the Marines in 2002, was a patient at VA facilities from 2006 to 2014 for a variety of con- ditions.

He was admitted on Aug. 10, 2014, to the Tomah VA Acute Psychiatric Unit, then transferred four days later to the Short Stay Mental Health Recovery Unit.

On Aug. 28, 2014, according to the lawsuit, Simcakoski met with Dr. Rhonda Davis, who after consulting with Houlihan, recommended starting Simcakoski on Suboxone, which is a combination of two drugs, one of which is an opioid, to relieve his chronic pain and potentially decrease his level of anxiety.

It was an off-label use for the drug combination, which is approved to treat people with opioid addiction.

According to the lawsuit, the dispensing pharmacist should have warned Davis and Houlihan that Suboxone would interact with other drugs Simcakoski was already taking.

When Simcakoski’s family visited the morning of Aug. 30, 2014, his father, Marv Simcakoski, was concerned because his son was so sedated he could barely speak, but was told that he would be fine in a few hours.

Early that afternoon, Simcakoski was seen asleep and snoring, and had not gotten up for lunch or taken his noon medications.

About 1½ hours later, a nursing staff member found him unresponsive. CPR wasn’t started for another 10 minutes and was unsuccessful.

Simcakoski was pronounced dead.

The Monroe County Medical Examiner’s Office said Simcakoski died from mixed drug toxicity.

A later review by the VA Office of Inspector General found that the respiratory depressant effects of the drugs that make up Suboxone, together with diazepam, was the plausible cause of his death.

The review also found that both doctors who prescribed Suboxone failed to talk with Simcakoski about the risks of the treatment. The Inspector General’s report also noted delays in the initiation of CPR and the lack of medication at the Tomah VA to reverse drug overdoses.

The lawsuit alleges that the VA failed to diagnose and treat Simcakoski’s bipolar disorder and depression, and failed to competently diagnose and treat his substance abuse problem.

It also alleges that the VA allowed Simcakoski to influence the choice and level of drugs he received, even to take an entire month’s supply in a week or two.

“The VA, at times, would even send opioids and other drugs to Jason’s home through the mail, allowing him to have access to large amounts of opioids even though he had a known opioid abuse problem,” the lawsuit states.


Ed Treleven is the courts reporter for the Wisconsin State Journal.