Tomah VA Malpractice

Wisconsinites Speak Out Over Tomah VA Malpractice

Benjamin KrauseThe Tomah American Legion held a town hall meeting for citizens outraged over Tomah VA malpractice that left many veterans harmed or dead. Representative Nancy VanderMeer hosted the meeting.

I drove to Tomah, Wisconsin to attend the meeting and help victims gather medical records following a veteran death caused by VA malpractice. There were two things that struck me about the meeting.

First, many of the participants were perplexed as to how to get access to their records, whether employees or veterans. Second, veterans’ stories reiterate what we all know about VA health care – when it is good it is really good, but when it is bad, it is deadly.

Most of the meeting focused on Dr. David Houlihan. He was for the former head of the facility known locally as Candy Land. Dr. Houlihan is linked to the death of one veteran due to excessively toxic prescriptive practices. Many at the meeting believe many more veterans were harmed by irresponsible decisions the psychiatrist made.

RELATED: Dr. Houlihan AKA Tomah VA Candy Man

If true, this means Houlihan engaged in negligent if not reckless treatment of veterans that caused harm and death. Veteran families affected by such negligent treatment should consider filing tort lawsuits against Houlihan and the VA. You can start by getting a copy of your medical file and filing an SF-95 Claim Form.

RELATED: Tips to filling out SF-95 Claim Form



The Tomah VA facility is amazingly huge. This is surprising given that the complex was built in the middle of a small Wisconsin city. It currently rests on 171 acres and includes a nine-hold golf course complete with a fishing pond.

It initially started as a Federal Indian Training School and was taken over by DoD during WWII to be used as a radio training school. After WWII, it was transferred to VA for use as a neuro-psychiatric hospital.

God only knows how many experimental procedures were conducted on unsuspecting veterans at the facility in its past?

Now, it functions as both a mental health facility and general medicine. The hospital has 1066 employees with 380 volunteers. These people serve approximately 25,000 veteran patients. Dr. Houlihan came to the facility in 2009 and took over as Chief of Staff a couple years later.


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  1. I cannot understand why the Fayetteville, NC VA Medical Center is not getting more spotlight. They had to close the ER down due to lack of staff. But the doctors had time to lie on veterans and deny services. I could not believe the veterans have to be seen when the time is accommodating to the staff and not the veterans. What kind of director manages a hospital and does not know the ER needs to be staffed?

    All the directors who have had things happen like this on their watch needs to be gone….What is the emergency room there for? So I guess you have to plan your heart attack.

    1. Carolyn, I have read your posts and I am sorry that the VA has treated you and your husband. I have looked at some sites to see what I could find and I will attach the links below. After reading what I could find in the short amount of time I spent looking, I completely agree that this VA needs a closer look.
      In the first link, a spokesperson for the Fayetteville VA states and I am taking this from the article just as it was put in there:

      “The bottom line is that we don’t have enough staff to provide some of these services, and this is not a secret,” said Jeffrey Melvin, spokesman for the Fayetteville VA. “People say it’s a scandal, but again this is VA-wide.”

      I have never heard of another VA shutting the ER down because of this. This guy claims that it is “VA-wide”? Really?
      here are the links so anyone who ants to see what this VA is doing:

      And I found this on a lawyer Website and I have the link if anyone wants it. I am going to put down a couple of parts on here that relate to this VA:

      A VA investigation found that a physician was responsible for misdiagnosed patient complaints and also failed to properly review medication information 56 percent of the time, a step that is “critical to appropriate evaluation, treatment planning, and safety.” Fayetteville VA Medical Center Director Elizabeth B. Goolsby received a performance bonus of $7,604.

      In a wrongful-death settlement against the Fayetteville VA facility, the agency paid out $750,000. The death was caused by the VA’s “failure to diagnose,” meaning a conclusion that the patient had no disease or condition.

      I hope this helps others to see that this VA is having some trouble.

  2. Enter Ryan Honl with experience at a number of pharmaceutical companies spanning an approximate 10 year time frame, then put him in a federal position and you have the perfect storm for him to jump on a whistle-blower accusation within weeks of employment.

    I had to ask myself why Honl is going to extensive lengths to drag any and everyone down. He is taking Dr. Houlihan down, he has referred to us as patients as “Houlihan ‘ s addicts,” while claiming to be representing us (laughable), is bad mouthing any agency who isn’t giving him first hand attention, and is the fore runner in the claim of being the original whistle-blower as well as mentioning how charges will be brought against the doctor.

    I ask myself why one goes to all this claiming to protect the very veterans Honl so freely slanders as addicts. Life battles usually entail at least one of two factors; power, money, or both.

    It didn’t take me long to find the Qui Tam program financially rewarding whistle-blower ‘ s who identify as the original source as Honl has. The reward is quite lucrative but in order to get it, he’d have to ensure a conviction. Not too difficult to see why he’s continuously fanning the flames in every media and public forum available. Heck, I’d take time off $8 an hour job if I knew down the road it’d get me over a million or possibly much much more.

    But one thing Honl isn’t expecting and that’s the veterans who were harmed in his aftermath who could sue for pain and suffering brought on by his degradation toward us referencing us as “addicts.” He forgot we are victims although he wants to portray us otherwise citing addiction or diversion. Guess what, there are a number of us who are not criminals in this and need medication which Honl ‘ s actions directly inhibited. I for one will be watching closely if Honl sues under Qui Tam and I will be filing suit for his tort actions in this matter.

  3. A little birdy called me and they spoke to another birdy who says it sounds like Houlihan will have his hands full with this state investigator guy. He’s got quite the reputation. Ever wonder why the VA investigators are in the papers every day and the state investigator stays outside of the limelight?

  4. I’ve been a patient of Dr. Houlihan for most of the time he’s been at Tomah. I was on the opiates for a chronic pain issue. Dr. Houlihan was not the primary prescriber until issues at other hospitals with veteran deaths started surfacing and around the same time complaints surfaced at Tomah as well. I have to commend Dr. Houlihan for taking the heat off his staff physicians and being the main prescriber of pain meds as the Chief of Staff. The media seems to misunderstand the doctor wore two hats. But back to my pain. My pain cannot be managed without medication due to damage on my body while serving my country. Dr. Houlihan went above and beyond to ensure I followed strict rules to be able to have the medication. First, I had to take a urinalysis as well as subsequent ones to ensure that not only was I taking the meds but to ensure I wasn’t abusing illegal ones. Second, I had to sign a contract under Dr. Houlihan promising I wouldn’t abuse my script. Third, for a short time (weeks) when I had to take oxycodone, Dr Houlihan ONLY did so after having my family member physically come in to his office to assure him they would dispense the oxycodone to me. The med was prescribed to me only 2 months. This was 2 months prior to the death of the man who died of toxicity. His death in no way reflects the safe practices Dr. Houlihan used with me at the exact same time period. To dispel other media accusations held of Dr. Houlihan: In going to see the doctor for over 10 years, I spent an abundant time in his waiting room with many others waiting to see him. In that time I never heard the doctor referred to as candy man nor did any of us refer to his area as candy land. I never saw anyone drooling or incoherent due their medication. It was typical to hold friendly group conversations with other veterans and the waiting room was a welcoming place among veterans to share stories. Dr Houlihan NEVER presented an authoritative retaliatory behavior at any time. In fact, he has a overly noticeable behavior of professional ease with an office staff who reflected his exceptional clinical presentation of tort basics of “first do no harm.” As for Mr Honl, I’ve never met him, nor do patients have any interaction with secretaries beyond scheduling appointments, but I find it deeply troubling he alludes to being involved in prescribing practices as a new secretary of only a few weeks. What’s even more troubling is reading of his completely unprofessional grabs at media attention and uses his military cadet credential as proof his claims are without question facts. Cadets often hold positions of authority in civilian job sectors; not as entry level secretaries in a small town bottom rung office support staff position. As for Dr Houlihan prescribing opiates thru his clinic, such was not the case until early 2014. In my case Dr. Houlihan did so as the Chief of Staff, not as a psychiatrist. I only can suspect this was a policy change to curb opiate prescribing practices among physicians employed at Tomah VA. I have, on two occasions witnessed obvious medication abusers seeking out pain medications in other clinics. One stated he needed 30 pain pills for the weekend and the other was begging for an early pain pill refill at the pharmacy. I never saw or heard anyone do this in Dr Houlihan ‘ s clinic. The disturbing part of this story is the harm done to the 128 patients who saw Dr. Houlihan. We lost our meds cold turkey and replacement of the meds is slow at best. You can imagine this media frenzy put so much fear into the staff, they don’t want to prescribe much without establishing a new patient rapport which takes a lot of time. For veterans like me who did lose some of the medications I relied on, it essentially feels like having the country turn it’s back on you. It’s like I did something wrong because the world is pointing it’s finger at a doctor who was nothing but fantastic to me as a patient. While everyone in authority is pointing their finger at each other to blame, they don’t even consider the 128 of us veterans who feel lost in this, without a doctor we could confide in, and without meds we long relied on to carry us through our likely long term ptsd journey. Letting the 128 patients of the doctor slip through the cracks is a worse disservice to us than any accusation could merit.

  5. I hope mr krause gets rid of the spam here and also responds to me so i will ask again mr krause please contact and let me know if you are available for legal counsel ad am i always now being charged 10 bucks a month? Sorry unclear thanks for.good work russellridge17 at gmail

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  7. I feel we have to keep fighting and demand these types of meetings and the VA’s top management to show up. If we do not act, we will not get the benefits that are deserved. Lets start to plan a meeting in DC with our elected officials as well as VA’s Secretary. We can meet and elect individuals to explain their specific issues. Say for example, I have mostly caregiver’s issues. I could prepare what it would take to make it better for the veteran with caregivers. Or if I complained about over dosing of my loved one I could present medical records to help to make my point.

    We need to act but as a group. There is strength in numbers!

  8. I worked with many Veterans, and I frequently heard them express fear of the government taking away their benefits. I’ve witnessed service-connected ratings reduced a couple of times, almost always due to examiners reporting that the Veterans’ conditions had improved, when in reality it was due the examiners being too lazy, not wanting to spend the time to do a thorough exam, or their personal and prejudicial bias that the Veterans were “malingering.” I was an examiner for about 10 years, and did my utmost to help Veterans get the full benefits to which they were entitled and deserved. Unfortunately, the examination process is designed to make it easier to find no disability, than to have to take the time to write up the evidence in the Veteran’s favor. I always encouraged Veterans to appeal adverse decisions, demand a different examiner as they are not all same in their approach and attitude, and most importantly, NEVER GIVE UP! I was able to get a couple of reductions reversed for Veterens, so you can successfully fight it. I do believe the fear is greater than the reality, but it’s a legitimate fear nonetheless. Not a government conspiracy, just a flawed system, with some bad C&P examiners.

    1. Really, Gerald? If it’s not a government conspiracy then what kind of conspiracy is it? Incompetence is the worst form of corruption. And the definition of conspiracy is: two or more persons agreeing to wrongfully harm or badly influence the life of one or more persons.

  9. It’s the “TOP COPS” that are not enforcing The Nehmer Court Order: The Nehmer Training Guide (211A) Feb. 2011 Revised; Congressional Research Services / Statutory Presumptions (by law clerk Nichols Oct. 2010) ; Title 38 ; and, to follow up to award compensation and provide health care. SCOTUS, Congress, and The President allows a hellish form of PTSD: Veterans were poisoned by their own country and abandoned. Proof is The Board of Veterans Appeals are BACK-LOGGED to 2012. yes, feel free: [email protected].

    I AM ORIGINALLY FROM MILWAUKEE, WI., attended Rufus King High(class of 67), UW-Platteville and Wisconsin University.

  11. We need more than “town hall meetings” to get this taken care of. The meetings are a place to start; however, I am still curious to see what will happen with the Tomah VA from the meeting. The one thing that I did not like to see (and it could have been different. This is only from seeing the video above) was the govt. still taking the lead on this. The state needs an independent investigation into this VA to get an accurate picture of what is happening. As long as the govt. is handling this it will not get a fair chance of getting resolved. I am saying that the govt. needs to be out of the investigation. We can’t trust the govt. now to help us so how and why should we expect any different results as long as the govt. is involved. The govt. will see to it that somehow this was found to be “only in isolated cases” or “blown out of proportion” or “have unfounded results” or some other cover their a** on this. An independent look at this would get an independent result. All states should look into the VA’s in their state the same way and let’s see what comes up in the end. Just my opinion.

  12. Why does it seem this new VA Secretary has no interest in attending such events to express CHANGE is taking place?
    This “Candy Land” and “Dr. Death” are like cockroaches in that if you see ONE, there’s usually a MINION of them lurking about, and this Dr. is but -1- of the MANY craptastic medical staff in VA Health System that should be terminated…but the way the crow flies, this Dr. will probably just be laterally promoted to some position like Surgeon General by this Presidential Administration and Congress…or retired with FULL PENSION, rather than having to face the consequences of his and the many staff’s grave disdain for our care.
    It’s great to see these “Town Halls”…but I think we need a HUGE Town Hall occupying all of the lawns in D.C., even with all the tear gas and probable arrests ensued to get our voices heard.
    We need an organized plan, Ben! Help us help YOU, Ben!
    Conversely, do you think many Veterans would simply be afraid of participating for fear of the VA taking away our benefits out of retaliation?

    1. I must add that as long as the VA “investigates ITSELF”, there will NEVER be any change as the OIG is certainly bedfellows with VA and do NOT have we Veteran’s best interests in mind…only tossing out “polished turds” in the form of Public Service Announcements.

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