As Winnipeg police Chief Devon Clunis finally acknowledged last week, there was a delay in police locating the two children who died so tragically in late July when they were drowned in the family bathtub by their postpartum-afflicted mother.
There was another delay in police taking responsibility, but Clunis said the service has learned from what he suggested was a mistake in the moment of a highly charged situation.
We now know those weren't the only delays surrounding the double homicide/suicide of Lisa Gibson and her children, Anna, aged two, and Nicholas, three months.
It turns out that nearly five months after the event, the College of Physicians and Surgeons of Manitoba has yet to deliver an official message to its membership about being vigilant when it comes to postpartum depression diagnosis and treatment. What makes that message important in a general way is the illness is under-diagnosed and under-treated, says the Canadian Mental Health Association website.
Gibson, who was a hospital pharmacist, had sought help from a physician for her condition. That much we know. What we don't know is how the physician treated her. But last month, in declining to call an inquest into the case, Dr. Thambirajah Balachandra, the province's chief medical examiner, essentially directed 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."
One would think the college would have been on that investigation soon after the event. And they may well have been. Provincial legislation prevents Dr. Bill Pope, the CEO and registrar of the college, from saying if it's investigating. But then there's the medical examiner's second directive we now know the college didn't initiate following the Gibson case. The directive to "take adequate action to educate the medical community to prevent similar tragedies in the future."
I only learned about the delay in the college's doing just that last week when, while doing the column on the police delay, I emailed Pope asking what directives, information or reminders about the postpartum treatment the college passed on to physicians after police found Gibson's body in the river early last August. By that time, I had already searched the college's website and found nothing on the subject.
Pope responded with an emailed statement: "CPSM is most certainly concerned about postpartum depression and psychosis. Our most recent newsletter, which goes out to all Manitoba physicians, was already sent out for printing and unfortunately, it was too late to add any further items."
That was the July issue of a newsletter that is usually mailed quarterly, according to Pope. The college registrar's email continued with this pledge:
"Our next newsletter will carry a reminder to all physicians to never lose sight of the serious nature of this illness and to be aware of resources that are available."
In anticipation of my next question, Pope added this: "The newsletter is a better forum for sending out information, because all members receive it, while the website may only be accessed by members irregularly."
A better forum in what age?
Pope acknowledged the college website is used to "immediately upload" any disciplinary actions. Yet he downplays its value to send out what should have been a bulletin on a subject of critical concern to the community.
Pope also said he had spoken with representatives of other health-care professions "with the view to co-ordinate our efforts" on the treatment of postpartum depression. But, he still hasn't communicated with the college's own members.
It was only after our last email exchange late Monday afternoon -- nearly half a year after three lives were lost -- Pope can say the newsletter and the message to the membership is "presently with Canada Post."
How does he justify the delay?
"I would suggest that there are very few Manitobans who were not made aware of this tragedy when it happened, and the publicity around the release of Dr. Balachandra's letter about three weeks ago re-emphasized this tragic illness."
If that's the case -- that we the media have done his job for him -- why bother finally doing your job now, Dr. Pope?
He had already anticipated that question, too.
"... I believe that a further reminder in the spring newsletter... will be the most effective way of ensuring members remain alert to the potential consequences of this illness."
What a lamentably unprofessional example of a professional body not exercising its responsibility in a timely manner. In any event, as Pope was suggesting, the college newsletter is in the Christmas mail. Meanwhile, here's a bulletin for the College of Physicians and Surgeons of Manitoba: The chief medical examiner shouldn't have had to remind you "to take adequate action to educate the medical community to prevent similar tragedies in the future."
And, the media shouldn't have had to ask you what took so long.