An inquest revealed that a young person who passed away after swallowing an object might have survived if medical professionals had acted promptly. Natalia Cestaro, known as Tali, was receiving care at the Caludon Centre, part of the Coventry and Warwickshire Partnership NHS Trust. She had autism and complex mental health issues, including emotionally unstable personality disorder.

Tali had a history of ingesting foreign objects impulsively. In September 2023, she swallowed an item that was removed via endoscopy. During the procedure, doctors noted a possible tear in her stomach wall but did not take further action. Tali later experienced worsening pain, but diagnostic imaging was delayed, and her condition was not escalated to the surgical team. By the time the gastric perforation and sepsis were identified, it was too late to save her.

After Tali’s tragic passing in November 2023, the NHS Trust acknowledged that appropriate specialized care might have saved her life. Described as bright and outgoing, Tali enjoyed watching musicals like Hamilton and Heathers, cooking, and sharing her experiences on Instagram.

Following the inquest, Tali’s family expressed their deep loss and gratitude for her organ donation, which impacted three lives. The coroner concluded that Tali’s death resulted from medical misadventure due to delayed imaging and failure to adhere to medical instructions. She highlighted shortcomings at the NHS Trusts involved and emphasized the need for improved communication between mental health and acute services.

In response to the findings, the UHCW NHS Trust expressed condolences and outlined changes made for patient safety. The Coventry and Warwickshire Partnership NHS Trust accepted the inquest’s conclusions, highlighting improvements in safety planning and patient support. They assured the coroner of ongoing efforts to enhance care quality.

Mental health support is available 24/7 in Coventry and Warwickshire via the national helpline 111. In emergencies, individuals are urged to call 999 or seek help from others.