BRANDON -- Without questions, there can be no answers. Without answers, more children could die.
Manitoba's chief medical examiner, Dr. Thambirajah Balachandra, says he won't decide until the late fall whether to call an inquest into the deaths of Lisa Gibson and her two children, Anna and Nicholas.
There is only one reasonable option available to Balachandra and no justification for delaying his decision. An inquest must be called and the sooner the better.
Anna, two years of age, and Nicholas, just three months, were found in the bathtub of the family's home on the morning of July 24 and were pronounced dead a few hours later. Lisa's lifeless body was found in the Red River four days later.
Media reports indicate Gibson had been diagnosed with postpartum depression days before the children died and prescribed medication to treat that illness. Though the Winnipeg Police Service is still investigating the incident, it is widely assumed the children were killed by Gibson, who later committed suicide.
Sadly, Nicholas and Anna are not the only murdered children in the thoughts of Manitobans this summer.
Retired judge Ted Hughes has just completed his lengthy inquiry into the death of Phoenix Sinclair, in which tough questions were asked of those who were responsible for the care of Phoenix and for the decision to place the child in the care of her mother, Samantha Kematch, who later participated in the killing of the child.
Following the completion of final arguments at the inquiry, an editorial in the Free Press stressed that "Mr. Hughes' task is to filter through the details of who did what, when and why to recommend ways to keep children from being left in the hands of dangerous parents or caregivers."
An inquest, or some other form of public inquiry, is required in the Gibson case for exactly the same reasons.
The inquest's objective should not be to assign blame or second-guess with the benefit of hindsight. Rather, it would serve the public interest by identifying the factors and events that combined to cause the three deaths, and the appropriate measures to be taken in futures cases in order to lessen the likelihood of such a terrible tragedy happening again.
While there are many questions specific to this case that must be answered -- did Lisa Gibson suffer from PPD or some other form of mental illness? If so, when was it diagnosed and how was it being treated? Were there any concerns she posed a danger to her children and herself? If so, what steps were taken to address that danger and why did they fail? -- an inquiry would also represent an opportunity for a much-needed discussion regarding the manner in which mental illness is diagnosed and treated in Manitoba, and how the best interests of children are considered in the context of the treatment of a mentally ill parent.
The inquiry could also examine the complex relationship between Manitoba's health-care system and child-welfare system, and recommend the appropriate measures to be taken in circumstances where the mental health of a primary caregiver may impact the well-being of children -- steps that either were not taken or failed in the Gibson case.
Some will argue an inquest is unnecessary and we should trust those working in "the system" to take whatever corrective measures are required on its own initiative. Unfortunately, the Phoenix Sinclair inquiry has shown significant systemic change seldom occurs behind closed doors and often requires the shove an investigation conducted in public can provide.
Others will argue the fact that infanticide is so rare when a mother suffers from PPD makes it impossible to predict such incidents, let alone prevent them. If that argument is correct, an inquiry would be pointless because we are powerless to prevent such deaths.
That argument is simply wrong, however. These three deaths were preventable. The issue to be determined is the extent to which they were (or should have been) foreseeable and what can be done in the future to more accurately identify the risks and prevent such tragedies.
That is why Balachandra must call an inquest. It could save lives.
Deveryn Ross is a political commentator living in Brandon.