An inquest revealed that a teenager who passed away after ingesting an object might have been saved if medical professionals had acted sooner. Natalia Cestaro, also known as Tali, was receiving treatment at the Caludon Centre, part of the Coventry and Warwickshire Partnership NHS Trust. She had autism and complex mental health issues, including emotionally unstable personality disorder.
Tali had a history of swallowing foreign objects impulsively. In September 2023, she swallowed an item that was removed through endoscopy. During the procedure, doctors suspected a partial tear in her stomach wall but did not take further action. Subsequently, Tali experienced escalating pain before her condition worsened.
Despite planned diagnostic imaging, it was not conducted as scheduled, and her deteriorating condition was not promptly escalated to the surgical team. By the time the gastric perforation and sepsis were identified, it was too late to save her.
Following Tali’s passing at University Hospital Coventry in November 2023, the NHS Trust acknowledged that appropriate specialist care could have potentially saved her life. Described as bright and outgoing, Tali enjoyed watching musicals like Hamilton and Heathers, cooking, and sharing her experiences on Instagram.
Her family expressed deep sorrow at losing Tali, highlighting the impact of her organ donation. The inquest concluded that Tali’s death resulted from medical misadventure due to delayed imaging and inadequate monitoring of her post-procedural condition.
The acting coroner noted shortcomings at the Coventry and Warwickshire Partnership NHS Trust and University Hospitals Coventry and Warwickshire NHS Trust, emphasizing communication gaps between mental health and acute services during patient transfers.
A representative from INQUEST emphasized the preventable nature of Tali’s death due to lapses in care at the mental health unit. Both NHS Trusts expressed regret over the incident, outlining steps taken to enhance patient safety and collaborative efforts to prevent similar tragedies in the future.
Individuals struggling with mental health issues in Coventry and Warwickshire were encouraged to seek support through available services, with emergency contact details provided for those in crisis.