Doctors should have acted sooner to save a teen with a severe mental health condition, an inquest has heard.
Natalia Cestaro, 18, was an inpatient at the Caludon Centre, at University Hospital Coventry in November 2023.
Natalia, known as Tali, had autism and complex mental health needs, including emotionally unstable personality disorder (EUPD).
Tali had a known history of impulsively ingesting foreign objects. In September 2023, she swallowed an item that was removed by endoscopy, the inquest was told.
Doctors suspected a partial tear in the stomach wall during surgery, but no further action was taken, the inquest heard. Tali later experienced increased pain before her condition deteriorated, reports CoventryLive.
Although diagnostic imaging was planned, it was not carried out as scheduled, and her condition was not escalated to the surgical team, the inquest was told.
By the time the gastric perforation and resulting sepsis were fully recognised, it was too late to save the 18-year-old.
After Tali died, the UHCW NHS Trust is said to have acknowledged she may have survived if appropriate specialist care had been provided.
She was described by her family as ‘bright and outgoing’ and loved watching musicals such as Hamilton and Heathers.
Her family said she also enjoyed cooking and always wanted to impress people with the dishes she created. Tali was also ‘deeply supportive’ of those with similar struggles and shared 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.”
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. She noted gaps in communication between mental health and acute services during inpatient transfers for physical health conditions.
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.”
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‘We are deeply sorry’
Both the UHCW NHS Trust and the Coventry and Warwickshire Partnership NHS Trust apologised to the family of Natalia. Safety planning has been strengthened for patients with complex mental health needs, they added.
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 said: “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, if you are struggling to cope, mental health support is available across Coventry and Warwickshire 24/7 by calling 111. If you have seriously harmed yourself or considering this, call 999 or ask someone to call 999 for you.”