Unlike many doctors, Albuquerque psychiatrist Edwin Bacon Hall, 74, accepted patients on Medicaid and saw them in a timely manner. He often treated foster children, who were sent his way with the approval of their legal guardian, the Children Youth and Families Department (CYFD).

On at least one occasion in his office, he prescribed drugs while dressed as a clown. But what really got attention was his prescribing practices.

“Hall has been a scourge of child psychiatry, and people have known about his bad practices for years,” said George Davis, CYFD’s former director of psychiatry. “He was widely known as one of the worst prescribers in New Mexico.”

Today, the longtime Albuquerque practitioner is under investigation by the New Mexico Attorney General’s Office in connection with the deaths of 36 patients, according to a search warrant filed in Bernalillo County District Court on Sept. 5.

Attorney General Hector Balderas declined to comment on whether any of the deaths involved a minor. But the ongoing investigation includes an examination of Hall’s prescriptions to both children and adults, he said.

The warrant accuses Hall of over-medicating 754 children in his care, prescribing an “elevated” number of psychiatric medications that were “outside normal prescribing habits.”

Law enforcement sources say Hall is also under investigation for alleged child abuse and Medicaid fraud. His attorney, Molly Schmidt-Nowara, declined to comment.

Agents with the state’s Medicaid Fraud Control Division are now scouring records and correspondence from the doctor’s Girard Avenue office. According to legal documents, the foster children in his care — including at least one child as young as 4 — received “egregious,” “unprofessional” and “illogical” quantities of psychiatric drugs.

Alyssa Otero, 21, recognizes this firsthand. At 14, after being in and out of foster care all her life, she was deeply depressed and taken to Hall for treatment.

“The first time I met him, he was in a clown outfit,” she says. “The orange hair, the makeup, the nose, everything.”

Otero, a youth leader for NMCAN, an Albuquerque foster care advocacy group, remembers it all too clearly.

“He didn’t say a word to me. He just handed me four months of prescriptions for Adderall. It was, ‘Here’s the prescription, here’s the prescription, here’s the prescription — goodbye.’”

Hall may be an extreme example, but his case highlights the state’s failure to protect children, a Searchlight New Mexico investigation has found.

“There are others like him out there,” Davis affirms. “If there was the slightest oversight, he would have been out of business 20 years ago.”

In 44 other states, psychiatric drug use is monitored by child welfare agencies, Medicaid or health offices, pharmacy boards or managed-care organizations — each of which can put the brakes on a runaway prescriber.

New Mexico agencies also have power of oversight. But even though CYFD workers approved Hall’s prescribing actions — signing off on each medication change — they neglected to stop him, according to foster treatment records reviewed by Searchlight New Mexico.

Davis tried. As head of psychiatry at CYFD, he says he repeatedly introduced measures that would “red flag” medical providers who abuse their prescriptive powers.  

A red flag works by triggering a peer review or demanding prior authorization when prescribing physicians deviate from “best practice” guidelines. For example, a doctor in Washington who prescribes more than three drugs to a 6-year-old can expect a specialist to intervene and review the case.

Davis says he first organized a task force in 2006 to study New Mexico’s over-medication problem and propose solutions. In 2013, the group proposed guidelines about medicating and properly monitoring children. They went nowhere, he says. In 2017, the task force issued a comprehensive report, formal guidelines and a cheat sheet to make the rules easy to follow. Neither CYFD nor Human Services Department (HSD) published them or made them enforceable, according to Davis.

In response to a request by Searchlight for the 2017 report, CYFD on Sept. 11 said there was “no written material on the topic.” Two weeks later, the agency reversed itself.

Bryce Pittenger, director of Behavioral Health Services, said the report did exist and “was not buried or put on a shelf.” She said it was emailed to HSD, the secretary of CYFD, the state’s four managed care organizations, Behavioral Health Collaborative and dozens of “stakeholders.”  

But she also acknowledged that publishing the report might be a good idea.

“I’ll have to ask the secretary about that,” Pittenger said.

It finally took a grandmother to spark an investigation into Hall’s practices. It happened in 2015 when she discovered her three grandsons were ingesting seven powerful psychiatric drugs a day. The drugs were prescribed by Hall, their psychiatrist during a two-year period when the children were in foster care.

Outraged, she sought the advice of a Santa Fe psychiatrist who alerted Davis, then head of psychiatry at CYFD. Davis, in turn, filed a complaint with the Medical Board; it included his review of the medical files for 15 children, nearly half of whom had received drugs that might interact in dangerous ways.

According to the search warrant, all 15 children were referred to Hall by Red Mountain Family Services in Rio Rancho, the same treatment foster care agency responsible for the three grandsons. Requests to Red Mountain for comment went unanswered.

The Medical Board revoked Hall’s license 17 months later, in October 2017. Among the reasons it gave were the numerous patients who had died while under his care.

Those revelations have so far led to three civil suits. Two charge Hall with negligence and fraud. One is a wrongful death suit filed in Second Judicial District Court on behalf of a 25-year-old mother of two. For four years, Hall gave her prescriptions for drugs such as benzodiazepine and alprazolam, both addictive sedatives, along with an amphetamine, the lawsuit says. She died of an accidental overdose Feb. 6, 2017.

Amy Linn has written about social issues and child well-being throughout her career, starting at the Miami Herald and including work for the Philadelphia Inquirer, San Francisco Examiner and Bloomberg...