An inquest has revealed that an 18-year-old girl with emotionally unstable personality disorder died after swallowing a deadly object, and her life could have been saved with timely medical intervention. Natalia Cestaro, known as Tali, passed away at University Hospital Coventry on November 15, 2023, while she was an inpatient at the Cauldon Centre mental health facility.
Background and Incident
Tali had autism and complex mental health needs, including emotionally unstable personality disorder (EUPD). She had a known history of impulsively ingesting foreign objects. In September 2023, she swallowed an item that was successfully removed via endoscopy, the inquest heard.
Doctors suspected a partial tear in her stomach wall during the procedure, but no further action was taken. Tali later experienced increasing pain before her condition rapidly deteriorated.
Failures in Care
Although diagnostic imaging was planned, it was not carried out as scheduled, and her condition was not escalated to the surgical team. By the time the gastric perforation and resulting sepsis were fully recognized, it was too late to save her. After Tali's death, the UHCW NHS Trust acknowledged she might have survived if appropriate specialist care had been provided.
Family's Tribute
Her family described her as 'bright and outgoing,' with a love for musicals like Hamilton and Heathers. She enjoyed cooking and always wanted to impress others with her dishes. Tali was also deeply supportive of those with similar struggles, sharing her experiences on Instagram.
Speaking after the inquest, her family said: 'Tali leaves a hole in our family that can never be filled. We will always be grateful for the time we had with our funny, passionate whirlwind of a girl, but forever devastated that our time with her was so short. Although Tali is no longer with us, her legacy lives on through the three people whose lives were transformed by her organ donation. We hope that the lessons learned will prevent another family going through what we have been through.'
Inquest Findings
Concluding the inquest on May 1, HM Acting Area Coroner Linda Lee found that Tali died from medical misadventure due to delayed imaging and not being kept without food or drink as instructed. She also noted delayed recognition and escalation of post-procedural deterioration by medical staff. Ms Lee highlighted failings at the Coventry and Warwickshire Partnership NHS Trust and University Hospitals Coventry and Warwickshire NHS Trust, citing gaps in communication between mental health and acute services during inpatient transfers for physical health conditions.
Selen Cavcav, from the inquest, stated: 'Tali died a preventable death whilst she was an inpatient in a mental health unit where she was supposed to be under the care of highly trained staff whose job it was to keep her safe. Unless inquest findings and recommendations are analysed and trusts are held accountable for failing to learn lessons and implement changes, we fear that deaths will sadly continue.'
Trust Apologies and Changes
Both the UHCW NHS Trust and the Coventry and Warwickshire Partnership NHS Trust apologised to Tali's family. They stated that safety planning has been strengthened for patients with complex mental health needs.
A spokesman for the UHCW NHS Trust said: 'We are deeply sorry for the loss of Natalia Cestaro and offer our sincere condolences to her family and loved ones. UHCW has implemented changes following a patient safety review, and we continue to work closely with the Coventry and Warwickshire Partnership Trust on a joint action, following a Prevention of Future Deaths Report, to improve liaison, shared responsibility and specialist input for patients with complex mental health needs.'
Officials at the Coventry and Warwickshire Partnership NHS Trust added: 'We fully accept the findings of the inquest. During the inquest proceedings, we outlined the improvements we have made, with a particular focus on strengthening safety planning and enhancing the support provided to patients while they are attending acute services. We are committed to learning from this case and will be writing to the coroner to set out our assurances, demonstrating the action taken to further improve the safety and quality of care we provide.'
Finally, mental health support is available across Coventry and Warwickshire 24/7 by calling 111. If you have seriously harmed yourself or are considering it, call 999 or ask someone to call 999 for you.
