Winnipeg Free Press - PRINT EDITION
No chance for lessons learned
Never before have so many branches of officialdom conspired to defeat the public interest.
We learned Wednesday there would be no inquest into the tragic death of Lisa Gibson. Last July, Gibson's two young children drowned in a bathtub in the family's Winnipeg home. Gibson's body was found several days later in the Red River. Police have said the death of the children was a homicide and Gibson's death was a suicide.
After studying the facts of the case for the past several months, the province's chief medical examiner, Dr. Thambirajah Balachandra, decided against calling a judicial inquest. Instead, Balachandra referred Gibson's case to the College of Physicians and Surgeons of Manitoba (CPSM) for investigation.
That decision ensures we will learn nothing more about the death of Gibson and her two children. Working independently, but still with the same general purpose, the health-care system, health professionals and the Winnipeg Police Service have decided to shield the larger community from any additional insight into this case.
Some may harbour hope the CPSM will help explain what happened. Those hopes are largely baseless. Even if the licensing body does investigate, the results will, in all likelihood, be kept confidential.
That is not, however, the only avenue of enlightenment that has been cut off. Both the Winnipeg Regional Health Authority and the police have already decided to conceal the facts of, respectively, an internal review and a criminal investigation.
In all instances, privacy provisions in provincial legislation governing medical records and criminal matters have been cited as excuses for the secrecy. Or, the blame has fallen to administrative provisions that allow various bodies, such as the CPSM, to keep a tight lid on any reviews or investigations. The WRHA even noted Gibson's family would prefer no additional information about the case be made public.
These are not insignificant concerns. But they are also not insurmountable problems when the public interest is at stake.
At one time, it appeared certain we would learn more about what happened. Early facts from the case, including confirmation she was being treated for postpartum depression, suggested there were important lessons to be learned.
Even as officialdom works to bolt down the lid on this story, many questions persist.
Was Gibson properly diagnosed? How many contacts did she have with the health-care system? And what kind of treatment did she receive? Did she refuse treatment? Did friends and family who may have seen her worsening condition take any action or urge her to seek more treatment?
There are also concerns about the response from the police. The Free Press has reported the children were discovered by their grandmother some 30 minutes after police arrived at the Gibson home.
Further complicating the police involvement is the fact it took investigators 71 days to declare the children's deaths homicides and Gibson's death a suicide.
Balachandra may have been justified in his decision not to call an inquest.
In a public statement about the decision, Balachandra said an inquest was mostly unnecessary because there was no mystery surrounding the cause of death for Gibson and her children.
However, statements by the medical examiner are often like court decisions: There is always a lot of information between the lines of a simple statement. And with his reference to the CPSM, we can deduce other facts about this case.
Balachandra has certainly focused some attention on the medical professionals involved in Gibson's treatment. Balachandra said he would like the college to investigate the "diagnosis, treatment and management of Lisa Gibson, and take adequate action to educate the medical community to prevent similar tragedies in the future."
It's important to note given the tragic consequences, it is unlikely Gibson suffered from routine postpartum depression. In fact, it has been theorized her depression had manifested as full-blown postpartum psychosis.
It would be instructive to know whether this was the condition Gibson was suffering from, and whether health professionals were equipped to respond to her needs. In the context of Balachandra's statement, it seems clear that at some point in her contact with the health-care system, someone misread or underestimated the severity of her condition.
We know in general the public, and indeed the health-care system itself, has many blind spots when it comes to mental illness. Was Gibson denied the help she asked for, or did she refuse the help she was offered? These critically important questions speak to the culture of our health-care system.
This was an opportunity to learn important lessons that would undoubtedly save other women. Officialdom's decision to lock away the deeper facts of this tragedy, instead, has all but ensured there will be more Lisa Gibsons in our future.
Republished from the Winnipeg Free Press print edition November 14, 2013 A3
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