An adolescent who passed away after ingesting an object might have been rescued if medical professionals had intervened earlier, an inquiry revealed.
Natalia Cestaro, known as Tali, was receiving treatment as a hospital patient at the Caludon Centre under the Coventry and Warwickshire Partnership NHS Trust. She had autism and complex mental health requirements, including an emotionally unstable personality disorder.
Tali had a record of impulsively swallowing foreign items, and in September 2023, the 18-year-old swallowed an object that was extracted through endoscopy, according to the inquiry. Surgeons suspected a partial tear in her stomach lining during the procedure, but no further action was taken, and Tali later endured escalating pain before her health deteriorated.
Although diagnostic imaging was scheduled, it was not performed as planned, and her condition was not elevated to the surgical team, the inquiry disclosed. By the time the gastric perforation and ensuing sepsis were eventually identified, it was too late to save the teenager.
After Tali’s passing at University Hospital Coventry in November 2023, the NHS Trust admitted that she might have survived with appropriate specialized care. She was characterized as “intelligent and outgoing” and had a fondness for musicals like Hamilton and Heathers.
Her family mentioned that she also enjoyed cooking and always aimed to impress others with her culinary creations. Tali was described as “deeply supportive” of individuals facing similar challenges and shared her journey on Instagram.
In a statement following the inquiry, her family expressed, “Tali has left an irreplaceable void within our family. We cherish the time we spent with our witty, passionate whirlwind of a girl but are devastated that our time together was cut short.
“Although Tali is no longer with us, her legacy continues through the three individuals whose lives were changed by her organ donation. We trust that the insights gained will prevent other families from enduring what we have.”
Concluding the inquiry on May 1, HM Acting Area Coroner Linda Lee determined that Tali’s demise resulted from medical misadventure due to delayed imaging and non-compliance with fasting instructions. She also highlighted the delayed acknowledgment and escalation of post-procedural deterioration by medical staff.
Ms. Lee underscored shortcomings at the Coventry and Warwickshire Partnership NHS Trust and University Hospitals Coventry and Warwickshire NHS Trust. She also noted communication gaps between mental health and acute services during patient transfers for physical health issues.
Selen Cavcav, from INQUEST, remarked, “Tali perished due to a preventable incident while under the care of highly skilled staff in a mental health facility tasked with ensuring her safety. Without analyzing inquest findings and implementing changes, holding trusts accountable for failure to learn from mistakes, we fear that such tragedies may persist.”
A spokesperson for the UHCW NHS Trust conveyed, “We deeply regret the loss of Natalia Cestaro and extend our heartfelt condolences to her family and loved ones. UHCW has enacted adjustments following a review of patient safety and collaborates closely with the Coventry and Warwickshire Partnership Trust on joint initiatives to enhance liaison, shared responsibility, and expert input for patients with complex mental health needs.”
Representatives from the Coventry and Warwickshire Partnership NHS Trust stated, “We fully acknowledge the inquiry’s findings. Throughout the inquiry proceedings, we elucidated the enhancements made, focusing on bolstering safety planning and enhancing support for patients during their acute service visits.
“We are dedicated to learning from this incident and will correspond with the coroner to outline our assurances, showcasing the steps taken to further enhance the safety and quality of care we deliver.
“Finally, if you are struggling, mental health support is accessible 24/7 across Coventry and Warwickshire by dialing 111. In case of serious self-harm or thoughts thereof, dial 999 or ask someone to do so on your behalf.”