Manitoba's chief medical examiner has ruled out calling an inquest into the deaths of Lisa Gibson and her two children.
Dr. Thambirajah Balachandra has determined the deaths of Gibson, 32, and her two children — Anna, 2, and Nicholas, three months — were preventable. However, a full inquest is not necessary, he ruled.
"Facts of this case are fairly straightforward and clear, and we know what's to be done and who should be leading the change," he said Wednesday.
"That's why we don't need an inquest in this case."
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Instead, Balachandra is recommending that the College of Physicians and Surgeons of Manitoba "investigate the diagnosis, treatment, and management of Gibson and take adequate action to educate the medical community to prevent similar tragedies in the future."
The children were found in a bathtub in their home on July 24, 2013. They had no vital signs and were rushed to hospital but were pronounced dead.
Police searched for Gibson for four days until her body was recovered from the Red River on July 27.
The cause of death in all three cases was determined to be drowning. The children's deaths were ruled as homicides while Gibson's death was a suicide.
She had a medical diagnosis of postpartum depression.
Balachandra said while health-care providers educate parents about caring for their babies, they should "also actively educate these mothers about the problems of postpartum blues, depression, psychosis, and also be on the lookout for signs."
The College of Physicians and Surgeons has not yet decided how or when it will proceed with the review.
Family members relieved
The Canadian Mental Health Association says it's not surprised to hear there won't be an inquest, but it hopes details from the review will be made public.
'An inquest would be very difficult because it would open up everything.' - Tara Brousseau-Snider
"The advantage of an inquest is that it's a very public thing. But I think that whatever is done here, there's an opportunity to educate the public," said Nicole Chammartin, executive director of the association's Winnipeg region.
Chammartin said she's interested in hearing exactly what the college's review will look like.
"Will it have public components? Will they gave the ability to talk to medical professionals that aren't necessarily physicians?" she said. "I do hope that it has those elements."
But a spokesperson for Gibson's family says relatives are still grieving and do not want an inquest.
"An inquest would be very difficult because it would open up everything," said Tara Brousseau-Snider of the Mood Disorders Association of Manitoba.
"No family that's lost anyone to suicide would welcome that. It's a time for families, when there's suicide, to heal and not have the wounds in the public forum."
In a statement, Health Minister Erin Selby said the Manitoba government respects the chief medical examiner's decision not to call an inquest.
"We respect the CME's request that the College of Physicians and Surgeons consider whether there are ways to prevent such tragedies in the future, we understand they'll be doing that. If they have advice for the province, we welcome that," she said.