Manitoba's chief medical examiner is recommending instead that the province's College of Physicians and Surgeons investigate the treatment 32-year-old Lisa Gibson received.
Police say Gibson drowned her two children — two-year-old Anna and three-month-old Nicholas — in their Winnipeg home's bathtub in July. Her body was found three days later in the Red River.
Dr. Thambirajah Balachandra said Gibson was suffering from postpartum depression and had seen a doctor.
"We looked into her treatment, the diagnosis and how she died, and came to the conclusion that the facts are fairly straightforward and clear," he said in an interview Wednesday. "Therefore, there was no need for a lengthy inquest."
Balachandra suggested the College of Physicians and Surgeons should "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."
Balachandra wouldn't elaborate on what kind of treatment, if any, Gibson received.
"It's a tragic situation where all three lives could have been saved," he said. "The special thing about postpartum depression is that it comes only after pregnancy ... Once that period is over, the person is all right."
Registrar Dr. Bill Pope said the college is waiting to be formally notified by Balachandra's office before it decides what steps to take. The college could investigate to see if disciplinary action is needed or its standards committee could examine the case and make recommendations, he said.
"What we will be looking at is how can we do some sort of educational material that would encourage and remind physicians of the importance of this illness?"
The death of Gibson and her two young children touched many and prompted calls for an inquest to ascertain whether everything was done to prevent what happened.
At the time of her death, Gibson's Facebook page was full of happy pictures of her two children: curly-haired toddler Anna and baby Nicholas. The page included a family photo that appeared to be taken at a hospital shortly after the birth of Nicholas in April, along with a proud birth announcement.
The last posting was mid-June — a picture of Anna with the caption reading: "Man I love this kid."
The two children were found in critical condition at their home on July 24 and died in hospital. Their deaths were ruled homicides. Police scoured the river near the family home for Gibson. Her body was found by a canoeist three days later. Her death was ruled a suicide.
The decision not to hold an inquest came as a relief to some and a disappointment to others.
"I'm somewhat surprised," said Chris Summerville, executive director of the Manitoba Schizophrenia Society. "The questions will still be asked — what went right and what went wrong? The public will never know if something more could have been done to prevent future tragedies like this."
Tara Brousseau-Snider, executive director of the Mood Disorders Association of Manitoba, said she was happy for the Gibson family's sake that an inquest has been ruled out. But she said there must be a broader discussion about how to better support the 20 per cent of women who suffer from postpartum depression.
There should be hospices for new mothers and better awareness of postpartum depression before a woman even gives birth, she said.
"We need to start opening up community dialogue," Brousseau-Snider said. "We certainly see with the public outcry and the public outpour of grief that that is happening and it has to happen."