A teenager passed away due to ingesting an object, and an inquiry revealed that prompt intervention by healthcare professionals could have potentially saved her life.
Known as Tali, Natalia Cestaro was under the care of the Coventry and Warwickshire Partnership NHS Trust at the Caludon Centre. She suffered from autism and complex mental health issues, including emotionally unstable personality disorder.
Tali had a history of swallowing foreign objects impulsively. In September 2023, she ingested an item that was removed through endoscopy. During the procedure, doctors suspected a partial tear in her stomach wall, but no further actions were taken. Unfortunately, Tali experienced escalating pain, leading to her deteriorating health.
Despite plans for diagnostic imaging, the procedure was delayed, and her condition was not escalated to the surgical team. By the time the gastric perforation and subsequent sepsis were properly identified, it was too late to save the teenager.
After Tali’s tragic passing in November 2023 at University Hospital Coventry, the NHS Trust acknowledged that appropriate specialist care might have increased her chances of survival. Described as vibrant and sociable, Tali enjoyed musicals like Hamilton and Heathers, cooking, and sharing her experiences on Instagram.
Her family expressed deep sorrow over her loss, emphasizing the impact she had through organ donation. The coroner, Linda Lee, concluded that Tali’s death resulted from medical misadventure due to delayed imaging and failure to adhere to dietary instructions. She also highlighted delays in recognizing and addressing her deteriorating condition.
Selen Cavcav from INQUEST criticized the preventable nature of Tali’s death and the lapses in care at the mental health unit. The UHCW NHS Trust expressed condolences and detailed changes made post a patient safety review to collaborate with the Coventry and Warwickshire Partnership Trust for enhanced patient care.
Officials from the Coventry and Warwickshire Partnership NHS Trust accepted the inquiry findings, outlined improvements made, and committed to enhancing safety planning and support for patients attending acute services. They urged individuals struggling with mental health to seek assistance through available support services.
