Clare Daly (Dublin Fingal, Independent) | Oireachtas source

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 we legislation for mandatory inquests in respect of maternal deaths will be forthcoming?

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