They never made it. Less than a mile from their destination, the buggy was rear-ended by a 1997 Dodge Caravan. The van wasn't moving fast, but as it passed by it suddenly swerved, knocking the carriage on its side. Miller and his son, John, were fine. But his wife, Elizabeth, who was cradling 6-week-old Ada Mae, was thrown from the carriage and landed on top of her daughter.
Ada Mae stopped breathing. An autopsy would list the cause of death as "crush injury to the chest."
A year later, after the driver pleaded guilty to vehicular homicide, William Miller wrote to the sentencing judge. "Words like grief, helplessness, anxiety, fear and lonesomeness come to mind," he wrote. "I would have scarcely thought it possible such a small infant could have left such a void. And the consequences and results have been far reaching and long lasting."
At first glance, the 2009 accident that killed Ada Mae would seem to have nothing to do with problems 60 miles away at the U.S. Department of Veterans Affairs hospital in Tomah, which earned the nickname "Candy Land" for its skyrocketing rate of opiate prescriptions. Some veterans called its chief of staff, psychiatrist Dr. David Houlihan, the "Candy Man." He was in charge for nearly a decade — and was one of the hospital's top prescribers.
But the man behind the wheel of the Dodge van that day was a Marine Corps veteran, and he was stoned on painkillers and tranquilizers from the Tomah VA. Brian Witkus was a known addict who "would fall or injure himself," court records say, to get "more pills or a higher dose of medication." His doctor, Witkus says, was Houlihan.
Ada Mae's death is one of dozens of tragedies that begin to hint at how the flood of narcotics from the VA scarred central Wisconsin, according to the Stevens Point Journal.
The repaired buggy that Brian Witkus hit while under the influence of pain killers and other drugs. The crash killed 6-week-old Ada Mae Miller, who was in her mother's arms when Witkus, who was under the care of VA Dr. David Houlihan, crashed into the buggy near Marshfield.
Photo Credit: Darren Hauck/Center for Investigative Reporting
It begins with the veterans themselves, who have become addled and addicted and who have overdosed. The collateral damage ranges from distraught sisters to fatherless children and dead girlfriends.
Patients of the Tomah VA have been arrested for dealing drugs, brandishing firearms in bars and passing out in the middle of the street. One totaled her truck and her car on her way to the VA.
Out in the community, police and prosecutors know these men and women so well that they refer to them by street names like "Turtle," "Airman," "Black Mark" and "Detroit."
Inside the hospital's brick walls, psychologists, nurses, social workers and the VA police just call them "Houlihan's Hooligans."
A search of Tomah police records by The Center for Investigative Reporting and the La Crosse Tribune found that employees at the Tomah VA called 911 more than 2,000 times in the past five years, seeking police help with cases of battery and burglary, an attempted kidnapping and 24 unexpected deaths.
Dr. G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins Bloomberg School of Public Health, has studied the widespread damage caused by opiates, which he attributes to their addictive potential and their ability to impair judgment.
In January, CIR disclosed that the number of opiate prescriptions at the Tomah VA had more than quintupled between 2004, the year before Houlihan became chief of staff, and 2012 — and that the federal government had all but ignored the problem for years.
Reached on his cellphone, Houlihan said he has been told not to talk while investigations into his prescription practices and management style are underway. On March 10, the VA announced he had been placed on administrative leave after a preliminary review found that Tomah patients were 2.5 times more likely than the national average to receive high doses of opiates.
The internal investigation also found that veterans' medications were not changed even "in the face of aberrant behavior."
Yet neither the VA's internal investigation nor any of the five other federal and state government inquiries launched in the past two months will begin to trace the insidious way the lack of VA oversight harmed a swath of Wisconsin, reaching from Tomah to Milwaukee, nearly 200 miles away.
Angela Colby died eight years ago after she overdosed on oxycodone. The pills were not hers; they were prescribed to her boyfriend, an Afghanistan War veteran, by Houlihan. Colby was 23.
Police arrived at the couple's studio apartment in Wausau before dawn to find Colby's boyfriend, Matthew Schuster, crying hysterically. He had called 911, he said, after finding Colby cold and without a pulse. He told the officers that the two had fallen asleep watching television and he hadn't noticed anything out of the ordinary until he returned to bed after grabbing a middle-of-the-night snack.
But when officers looked around the apartment, they quickly spotted signs of something amiss. The trash can was full of pill bottles from the VA. There were also tubes from ballpoint pens, minus the ink, used to snort the pills.
When police took Schuster back to the station, he told them that Colby had been snorting his medication.
Over the next few weeks, police in Wausau continued to investigate Colby's death and eventually referred the case to the district attorney, who declined to prosecute.
The rub, Wausau Police Chief Jeff Hardel now believes, is that the drugs were obtained legally.
"We have a major problem with prescription drug abuse, but I don't think we have a handle on it like we do with heroin and meth," Hardel said.
If heroin had been in the apartment, arresting Schuster would have been the logical course of action, Hardel said. But the VA had prescribed all of the drugs that officers found in his apartment. Investigating Houlihan, Hardel said, never occurred to him.
Court records and police reports contain four phone numbers for Schuster. All were disconnected.
Colby's death is one of at least five fatal overdoses with direct links to the Tomah VA while Houlihan was in charge. Some, like Colby, overdosed primarily on prescription medications. That was true for Jason Simcakoski, a 35-year-old former Marine from Stevens Point who died in the Tomah VA's psychiatric ward in August after Houlihan agreed that the opiate Suboxone should be added to a prescribed mixture of 14 medications.
Other deaths happened when prescription abuse accelerated into heroin addiction. This progression, seen around the country, contributes to a fatal overdose rate among VA patients that the agency's researchers have pegged at twice the national average.
"The effects produced by oxycodone and hydrocodone are indistinguishable from the effects produced by heroin," said psychiatrist Dr. Andrew Kolodny, chief medical officer of Phoenix House, which runs more than 100 drug treatment clinics nationwide.
Jacob Ward, 27, overdosed on heroin and cocaine in a Milwaukee apartment in September 2013. He was a patient at the Tomah VA, too, and his parents said he first was exposed to opiates in the psychiatric ward overseen by Houlihan.
On Oct. 8, 2012, 5-year-old Danielle Bobak awoke to find her father, Marine Corps veteran Michael Bobak, dead alongside his girlfriend, Tracey Small, in their home a half-mile from the hospital. A toxicology report by the University of Wisconsin School of Medicine and Public Health found that both had lethal doses of heroin in their systems, but Michael Bobak also had a long list of prescription painkillers and tranquilizers in his urine.
"He was supposed to take his daughter to preschool," said Michael Bobak's father, Cecil. "Instead, he was dead."
The day before he died at 26, Derik McGovern joined his three sisters and his mother for dinner at his grandmother's house. They shucked corn and put it on the grill with brats and hamburgers.
McGovern had faced his share of problems after he deployed to Iraq in 2008. He told family members that he had been shot in the stomach and a roadside bomb had wrecked his knee. VA doctors performed a series of surgeries on his knee, but his sister Hannah said the main treatment her big brother received was oxycodone.
"He was gone a lot," Hannah, 14, said in a Facebook message. "He got addicted. They gave him however many he asked for."
On July 1, 2014, McGovern died alone in his Tomah apartment of a heroin overdose, leaving behind an infant son, Lucian. McGovern's roommate found him. His arms, the autopsy report later said, were covered in track marks.
DEALING ON HOSPITAL GROUNDS
The tendrils of narcotic abuse crept inside the Tomah VA itself. In recent years, police reports and court records show veterans repeatedly have been caught with drugs on hospital grounds, sometimes even selling their recently filled prescriptions, while addicts have preyed on other patients and hospital staff.
Derik McGovern's roommate, Damien Ehlert, was among those arrested for dealing prescribed narcotics. In December 2013, VA police stopped Ehlert's maroon Ford truck after he swerved erratically on hospital grounds.
When police asked him why a bottle of oxycodone prescribed the day before was empty, Ehlert said he had been selling the VA-prescribed narcotics in front of the hospital's addiction treatment center.
Betty Sumiec is one of the victims of an addicted veteran. In February, the retired dairy farmer came to the Tomah VA to visit her husband, Edwin, an 88-year-old Army veteran who is paralyzed from the waist down.
Sumiec left her husband's room for a few minutes. When she returned, all her money was gone. VA police tracked down the thief in the parking lot. He was a 32-year-old Iraq War veteran with convictions for cocaine and heroin possession.
"He was a nice, fine-looking kid, but he talked funny," Betty Sumiec said. "The police said he was a druggie. That's why he talked the way he did."
The perpetrator, Jacob Zimmerman, pleaded guilty to petty theft and was granted leniency on the condition that he apologize to Betty Sumiec. But she says that apology never came.
Five months after the theft, a police officer in Adams, Wisconsin, found Zimmerman passed out in the middle of the street with a .40-caliber Smith & Wesson handgun sticking out of the bottom of his shorts. Zimmerman told police that he wasn't sure how he ended up with the gun. Perhaps someone drugged him, he said.
Timothy Benton goes by the street name "Turtle." Hospital staff have been concerned about the Marine Corps veteran since at least July 2013, when a medical resident complained that Benton, then 33, "approached him in the elevator and asked him to 'get high.' " The exchange was caught on security cameras.
Officers also tracked Benton down in the VA parking lot, where he was cutting his toenails with a knife next to his Ford Ranger pickup, with a pit bull in the cab.
When one of the officers asked to search his backpack, Benton said, "All I have is extra clothes," according to court records. But inside, they found a hypodermic needle, pen tubes and cotton balls — all covered in an unidentified fine residue.
Ehlert, Zimmerman and Benton could not be reached for comment.
The dangers posed by the criminal activity created considerable tension between Houlihan and the police who patrol the hospital.
Lori Hensley, chief steward of the American Federation of Government Employees local that represents rank-and-file officers at the facility, traces the law-breaking to a policy Houlihan implemented in 2010. It required his approval before any veteran could be arrested on the premises. The policy also required that any prescriptions had to be written and ready to go before a veteran could be arrested.
On Dec. 6, 2010, Hensley wrote to Houlihan to protest, labeling her email: "VA Police Officer Safety Concerns."
The "time it takes to get this type of communication completed could put many at high risk of getting hurt," Hensley wrote. "What happened to past practice in which our highly trained professional VA Police Officers were given authority to intervene as needed?"
Houlihan brushed those concerns aside. "The veterans are patients above all," he emailed back a half hour later. "That they are in a hospital is an indication that they are in a potential state of crisis. To arrest without taking this into consideration puts the veteran at risk."
Current and former employees also tried to go above Houlihan. They wrote to their congressmen and senators, filed whistleblower complaints, even exchanged emails directly with VA Secretary Robert McDonald.
Fed up, nursing assistant Janelle Arnold said that last year, she confronted Houlihan's boss, Mario DeSanctis, director of the Tomah VA.
She called Houlihan the Candy Man, she remembered, telling DeSanctis: "Your own chief of psychiatry hands out narcotics like they're candy. … I know I've had people come to me and say that they can get narcotics from him."
But DeSanctis, she said, "sat back in his chair and laughed."
DeSanctis, however, says no one used the phrase "Candy Land" or "Candy Man" in his presence before CIR revealed widespread problems at the hospital in January. On Friday, the VA told Congress that DeSanctis "has been reassigned to a position at the Great Lakes Health Care System network office, a position outside of the Medical Center."
The body of baby Ada Mae Miller is buried in a simple grave a half-mile from the Millers' family farm. The buggy was fixed long ago. More than five years after Witkus took his daughter's life, William Miller said his family has begun to recover.
"Obviously, you never forget," he said, his voice quavering with emotion, "but we don't live in the fear and dread that we did after the first months."
Miller was not aware that drugs were a factor in the crash, and he declined to discuss the role VA-prescribed painkillers could have played in the accident beyond saying that "abusing narcotics is wrong. If he was doing it, that was a factor in the accident, that's why he was convicted in court."
Religion offers some solace. "Perspective brings compassion," Miller said. "We believe in allowing God control of our life. Why he allowed this to happen, we won't know until the other side. The only thing for us to do is accept and move on."
As for Witkus, he served three years in prison and was released after completing a drug rehab program. Today, he lives in a halfway house in Wausau. His beard is gray, his face haggard and he walks with a cane.
His main complaint is that as a condition of his parole, he is no longer allowed to take tranquilizers, while the amount of painkillers he's being prescribed has been cut in half.
He remembers Houlihan as a good doctor.
"He was pretty understanding," Witkus said. "He didn't really push the meds on me. I think he's an awesome doctor."
During a 45-minute conversation in January, Witkus never mentioned the Millers' baby. Asked if he had anything else he wanted to say, he brought up a conversation he once had with a psychiatrist.
"I had a psychiatrist when I was in prison over in Jackson County, over in Black River Falls," he said. "She was a student and she asked me, she says, 'With all your bad things that happened to you, what would you change in your life?' I said, 'Ma'am, I would not change a thing.' "
Chris Hubbuch of the La Crosse Tribune contributed reporting to this story. This story was edited by Amy Pyle and copy edited by Sheela Kamath and Nikki Frick, with additional editing by Peter Wasson of Gannett Wisconsin Media.