Six years ago this week, 31 year old Nora Hyland died in Holles Street hospital. She died from a cardiac arrest as a result of a massive haemorrhage after giving birth to her son, Frederick, by emergency caesarean section. There were no emergency blood supplies in the operating theatre. The coroner believed that the 37-minute delay in getting a transfusion probably cost her her life. Holles Street said it would rectify this situation but although fridges were installed in theatres, they were not sufficiently stocked when Malak Thawley bled to death in the same hospital in May 2016.

Five years ago yesterday, while giving birth to her fourth child, Sally Rowlette died in Sligo General Hospital as a result of a catastrophic mismanagement of HELLP syndrome, the same condition as a result of which Dhara Kivlehan died in the same hospital a few years earlier. The HSE's brutal opposition to the truth coming out, fighting her husband, Michael, for four years and resisting that inquest, probably cost Sally Rowlette her life and her children their mother.

We are hearing a lot lately that Ireland is one of the safest countries in which to give birth but when something goes wrong, there is no appetite for transparency or no appetite to learn. It is a battle every time with the bereaved and stunned families on one side and the HSE lawyers on the other. It is a case of litigate, delay and deny. That is the HSE way. The report on Portiuncula University Hospital still has not been released. Investigations were ongoing in seven out of the 19 maternity hospitals last year. Twice in the past three years, the HSE has gone to court to prevent the truth coming out, first, to prevent the Health Information and Quality Authority, HIQA, publishing the report on Portlaoise and, now, Holles Street hospital effectively taking the Minister to court to stop an external investigation into Malak Thawley's death.

There is something very wrong in our health service. There were 27 maternal deaths between 2011 and 2013 but only three inquests. The culture of deny and defend has to end. While I welcome the Minister's measure to have an external investigation, the reality is that mandatory inquests in respect of maternal deaths are a key step in ending this culture and improving maternity care. That is something on which this House has agreed since Second Stage of my legislation was passed in the dying days of the previous Dáil. That legislation was prioritised by the current Joint Committee on Justice and Equality. We gave the Department of Justice and Equality six months to table amendments. On the night before the committee hearing, it pulled the plug and did not proceed with that investigation. The legislation in question is supposed to be a priority for the Government.

Two years ago, the Taoiseach met Sean Rowlette, who gave him a letter from his children in which they said they miss their Mam every day. Can the Taoiseach ensure that this will never again happen to another mother? Since the meeting to which I refer, it has happened at least twice. Will the Taoiseach indicate when the legislation for mandatory inquests in respect of maternal deaths will be forthcoming?

I would like once again to extend my condolences to the families of the women Deputy Clare Daly mentioned. As she is aware, I met some of those families when I was Minister for Health and I know they still suffer every day from the loss of their loved ones and as a result of the traumatic events that occurred to them. My sympathies and those of the House are with the families.

Ireland is one of the safest countries in the world in which to give birth, both in terms of maternal mortality and neonatal mortality. However, that should not give rise to complacency in any way because we need to ensure that the number of maternal deaths and neonatal deaths is minimised. It is never possible to eliminate them entirely but they can be reduced further and minimised. Any time a maternal death occurs, there should be total transparency. Hospitals should be upfront about what happens and should carry out full investigations so that lessons can be learned and further events avoided into the future.

In terms of the actions of the Minister for Health, Deputy Harris, Deputy Clare Daly will know that he has sought an independent review of the Thawley case, and the Government is totally behind him in that regard. We are very disappointed and dissatisfied that Holles Street hospital is threatening to take the Minister or the HSE to court in order to avoid an external inquiry. There should be an external inquiry. Rather than trying to block it, the hospital authorities should welcome it. If they have nothing to hide, they should welcome it. We are totally behind the Minister in that regard.

Legislation was passed in recent months to provide for open disclosure. As a result, for the first time open disclosure by doctors and other health care professionals is protected. I know that was a long time coming but it has now been done and it is important that we turn this legal mechanism into a culture and a practice across our hospitals whereby doctors and health care professionals are upfront with patients and their families when something goes wrong and understand why it is in their interest to be upfront. We know that is the case for many different reasons.

In terms of inquests, that legislation is under consideration.

There are strong arguments in favour of a mandatory inquest in the case of every maternal death but there may be cases in which that is not appropriate, for example, where a family does not want one. We have cases of maternal death where it is known immediately why the mother died. An inquest may not be necessary in such cases. However, there is a strong basis for a mandatory inquest where the family requests it.

I welcome the Minister for Health's initiative to put in place an external review, but it is not enough and it is not a substitute for an inquest. There are a lot of questions around the review, including what the terms of reference and qualifications of a reviewer will be and whether it will be capable of public scrutiny. There is something very wrong in the Department of Justice and Equality. I wonder whether we would be waiting this long if men were dying. Both the former Tánaiste and Minister for Justice and Equality, Deputy Frances Fitzgerald, and the current Minister, Deputy Flanagan, gave me guarantees that the legislation was a priority matter for them and the Government. Objections such as those the Taoiseach has raised are obvious and have already been dealt with. It is a priority for the whole of the justice committee. Local authorities the length and breadth of the country and representatives from all parties and none have supported this call. Nevertheless, the Department of Justice and Equality, which promised that we would have this legislation through every Stage before the summer, has yet to deliver the heads of a Bill.

The justice committee, on which Deputy Ó Caoláin and I sit, has met with the Department's officials. Either they do not understand what priority is or they are not listening to the Taoiseach's Ministers. There is no excuse for this. Babies have been conceived and delivered in the time the Department of Justice and Equality told us the legislation would be seen through every Stage. It is about fighting for better maternity care. We need these measures and we need the Taoiseach to get behind forcing the Department to stop messing about and simply deliver the legislation.

The Minister for Health has already announced that all deaths in maternity hospitals will be subject to an external review, which is necessary and welcome. It is also a provision of the national maternity strategy which was published not too long ago. I am advised by the Chief Whip and the Minister for Justice and Equality that this legislation is on the A list and that he intends to publish it this month. If it is published this month, we can perhaps get it through the Houses sooner rather than later. I have no doubt the Deputy will hold us to account in that regard.