A provincial inquest into the deaths of Lisa Gibson and her two children isn't necessary, the province's chief medical examiner said Wednesday.
Instead, Dr. Thambirajah Balachandra referred the case to the College of Physicians and Surgeons of Manitoba, the governing body for all doctors in Manitoba, to investigate and take "adequate action" to educate the medical community to prevent similar tragedies.
Gibson, who suffered from postpartum depression, killed her young daughter and infant son before taking her own life last summer. Two-year-old Anna and three-month-old Nicholas were found unresponsive in a bathtub at the Gibson home on July 24. Gibson's body was recovered from the Red River a few days later. Winnipeg police have said she drowned her two children and then took her own life.
'We know what happened. There's nothing more to dig into how she died and the circumstances' -- Dr. Thambirajah Balachandra
Balachandra said he wants the college to examine Gibson's treatment for postpartum depression, because there is nothing an inquest could answer that isn't already known.
"We know what happened," Balachandra said. "There's nothing more to dig into how she died and the circumstances. We know these were preventable deaths. We know what could be done and who could do it. It is the medical community."
Balachandra also said Gibson, 32, had a medical diagnosis of postpartum depression and was being seen by a doctor. The Free Press has reported Gibson had reached out for help and saw a doctor on July 18.
She was diagnosed with a postpartum illness and given medication. Former health minister Theresa Oswald has said a preliminary review of Gibson's contact with the health-care system indicates normal protocols were followed in her care.
Balachandra said it's now up to the college to determine whether it's appropriate to investigate Gibson's treatment.
"We have no rights to take punitive action or suggest punitive actions," he said. "We have informed the college of the patient's name and the doctor's name and they will do more in-depth study about what exactly happened between the two and then go from there."
College registrar Dr. Bill Pope said the organization can take a number of steps, including looking at the broader issue of treatment of postpartum depression and amending the standards of practice doctors are expected to follow.
Pope said once he's gone through Gibson's medical file, he could refer the matter to the college's complaints committee as a complaint against Gibson's attending physician.
"If we do that, then the only thing that can be public from that at the end of it is if the doctor is either censured or there is an inquiry with a finding of fault or formal discipline," he said. "When that happens, it goes up on our website immediately."
Pope added the college will also do a review of all deaths of children under 18 for the year -- it does these reviews every year -- to pick out any trends. Past reviews led to the province making bicycle helmets mandatory for cyclists under 18.
Pope also said he can address the matter in a newsletter, which is sent out to the profession about four times a year.
"I'll be considering that very seriously," he said.
"Certainly there are times when our members, they have so much coming at them all the time, that certain aspects have to be reinforced. It just really is more a matter of trying to ensure that this is kept in the front minds of physicians who are treating patients with postpartum depression."
Would an inquest be more likely to result in improved services for women suffering from postpartum depression and psychosis? Join the conversation in the comments below.