Natalia Cestaro: Prevention of future deaths report

The conclusion reached at inquest was: 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 medical cause of death was:
1a Septicaemia and Multi Organ Failure
1b Gastric Perforation
1c Ingestion of Foreign Object

On 5 November 2023, Tali ingested a [REDACTED] and was transferred to University Hospitals Coventry and Warwickshire NHS Trust for endoscopic removal. The [REDACTED] was removed endoscopically. During the procedure a partial-thickness tear to the stomach wall was suspected. At that stage it was not considered to be a full-thickness perforation and immediate surgical intervention was not undertaken.

The period following the procedure was critical. Tali experienced increasing pain and clinical deterioration. Diagnostic imaging was planned but did not take place at the time intended. Concerns arising during this period were not escalated to the surgical team, and Tali was not consistently maintained nil by mouth following the procedure.

By the time the gastric perforation and associated sepsis were fully
recognised, Tali had deteriorated significantly. Emergency intervention took place, but her condition was no longer reversible, and she died on 15 November 2023. It was acknowledged by UHCW that on the balance of probabilities, Tali would have survived if there had been an appropriate referral to the surgical team.

Evidence was given by witnesses from CWPT and UHCW regarding the steps taken following Tali’s death. In particular, the evidence from UHCW described significant changes to escalation arrangements, diagnostic pathways and governance oversight. Those matters have been taken into account when determining whether the statutory criteria are met in respect of this report and, if so, the scope of the concerns identified.

a) Proactive scope of risk assessment for impulsive ingestion (CWPT)
The evidence raised a concern that risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment. Where a patient is known to present a persistent risk of impulsive ingestion, a predominantly reactive approach risks foreseeable hazards not being identified and mitigated in advance.

b) Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW) The evidence before the inquest disclosed limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare. While both organisations described mechanisms for access to advice and communication, there was relatively limited evidence of how these arrangements operate reliably, how compliance is assured, and how lapses are detected and addressed. This creates a risk that relevant mental health risks are not consistently carried through the acute admission.

c) Assurance and auditing of expected communication processes (CWPT) The evidence raised concern that processes described as standard practice, including regular contact following transfer, may not be subject to routine auditing or assurance. Reliance on the existence of a process alone, without effective oversight of whether it is consistently carried out in practice, risks failures persisting undetected.