A teenager with complex mental health needs died at University Hospital Coventry after doctors failed to act quickly enough, an inquest has concluded.
What happened to Tali Cestaro?
Natalia Cestaro, known as Tali, was 18 years old and an inpatient at the Cauldon Centre mental health facility when she died on November 15, 2023. She had autism, emotionally unstable personality disorder (EUPD), and a known history of impulsively swallowing foreign objects.
In September 2023, Tali swallowed an item that was removed by endoscopy. During the procedure, surgeons suspected a partial tear in her stomach wall but took no further action. Despite experiencing increasing pain, diagnostic imaging was not carried out as scheduled, and her condition was not escalated to the surgical team. By the time the gastric perforation and sepsis were fully recognised, it was too late to save her.
Inquest findings
HM Acting Area Coroner Linda Lee concluded that Tali died from medical misadventure due to delayed imaging, failure to keep her nil by mouth as instructed, and delayed recognition and escalation of post-procedural deterioration. She highlighted failings at both the Coventry and Warwickshire Partnership NHS Trust and University Hospitals Coventry and Warwickshire NHS Trust, noting gaps in communication between mental health and acute services during inpatient transfers.
The UHCW NHS Trust acknowledged after Tali's death that she may have survived if appropriate specialist care had been provided.
Family tribute
Tali's family described her as 'bright and outgoing', a fan of musicals like Hamilton and Heathers, and a keen cook who loved impressing others with her dishes. She was also deeply supportive of people with similar struggles and shared her experiences on Instagram.
In a statement 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.'
Trusts respond
Both trusts apologised to Tali's family. A UHCW spokesman 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 to improve liaison, shared responsibility and specialist input for patients with complex mental health needs.'
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.'
Selen Cavcav from INQUEST said: '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.'
