Teenager died following hospital care issues

Tali Cestaro, aged 18, died on 15 November 2023 at University Hospital Coventry and Warwickshire (UHCW) while she was an informal patient at the Caludon Centre under the care of Coventry and Warwickshire Partnership NHS Trust (CWPT).

Tali was autistic and had complex mental health needs, including emotionally unstable personality disorder (EUPD). She had a known history of impulsively ingesting foreign objects.

In November 2023, Tali ingested a foreign object which was eventually removed by endoscopy.

After the procedure, Tali experienced significant pain and clinical deterioration. Having had similar procedures carried out before for ingestion of foreign objects, Tali expressed the pain to be significantly more.

Although diagnostic imaging (a CT scan) was planned, it was not carried out at the time it should have been. Further, there was inadequate handover of Tali’s care from the surgical to emergency cover team – Tali should have been documented as a patient for senior review, but wasn’t. As a result, Tali did not receive senior review the next morning and the urgency of the planned CT scan the following morning was not acknowledged.

Tali's worsening condition was then not escalated to the surgical team.  Tali developed sepsis and by the time the gastric perforation and resulting sepsis were fully recognised, it was too late to save her.

It was acknowledged by UHCW following Tali‘s death that on the balance of probabilities, Tali would have survived if there had been an appropriate referral to the surgical team to ensure the CT scan was carried out and her deterioration escalated.

It was also acknowledged by CWPT following Tali’s death that there was a poor transfer of care from CWPT to UHCW, failing to handover the complexity of Tali’s mental health conditions, her needs, and even her medication. Since Tali’s death, CWPT have implanted measures to improve transfer of care and communication between the mental health and acute hospital.

Concluding the inquest on 1 May 2026, HM Acting Area Coroner Linda Lee found that Tali’s death resulted from: “Medical misadventure against a background of delayed recognition and escalation of post-procedural deterioration, delayed imaging, and failure to maintain nil-by-mouth instructions.”

The Coroner, also made a Prevention of Future Death Report, towards both UHCW and CWPT, highlighting deficiencies in risk assessing impulsive ingestion and communication between mental health and acute services when a mental health inpatient is transferred to an acute hospital for physical healthcare. The Trusts have a duty to respond to the coroner's report by 9 July 2026.

Tali was described by her family as bright and outgoing. She adored musicals and had a powerful singing voice; Hamilton and Heathers were among her favourites. She loved cooking and was ambitious in the kitchen, always wanting to impress others with the dishes she created. She was also deeply supportive of others in the recovery community, sharing her experiences of autism on Instagram and posting messages to encourage and uplift others.

Speaking after the inquest, Tali’s 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”

Tali’s family have been represented by specialist public law and human rights lawyers at Irwin Mitchell.  

Eliza Fleming the lawyer supporting Tali's relatives said:

“Tali’s loved ones remain devastated by her death and the tragic circumstances surrounding it.  

"The family have had a number of concerns about the events that unfolded in the lead up to Tali’s death. Sadly, the inquest has vindicated those concerns. 

"While we’re pleased to have secured answers the family deserve, nothing can make up for their loss. It’s now vital lessons are learned and improvements made to better protect other patients.”

Selen Cavcav, co-lead of Casework at the charity INQUEST said:

“Tali died a preventable death whilst she was an informal patient 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. 

"The fact that some of the failures in her care has been recognised and strong recommendations have been made is a step in the right direction but 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."

The inquest into Tali's death was heard between 30 April-1 May 2026.