University Hospital Coventry has appointed a specialist nurse after the death of an autistic teenager exposed failures in the care provided to patients with learning disabilities. Natalia ‘Tali’ Cestaro died after a partial stomach tear was missed, an inquest heard.
Natalia, 18, was an inpatient at the Caludon Centre, which is run by the Coventry and Warwickshire Partnership NHS Trust. She had complex mental health needs, including emotionally unstable personality disorder, as reported by CoventryLive.
Tali had a known history of impulsively swallowing foreign objects. She ingested an item which was later removed during an endoscopy, the inquest was told.
Doctors suspected a partial-thickness tear to the stomach wall during her surgery on November 5, 2023. At that stage, it was not considered a full-thickness perforation and immediate intervention was not required.
Tali experienced increasing pain and clinical deterioration alongside delays to planned diagnostic imaging. Concerns arising during this period were not escalated to the surgical team, the inquest heard.
Tali was not consistently kept from eating or drinking following the procedure and later developed a gastric perforation and resulting sepsis. She died on November 15, 2023.
After Tali died, the UHCW NHS Trust acknowledged she may have survived if appropriate specialist care had been provided. Learning Disability and Autism Nurse Specialist Leona McCook has since been appointed and is working to remove barriers to treatment and improve access through reasonable adjustments.
Leona helps staff provide better support for patients with learning disabilities by identifying signs of pain or distress and supporting smoother discharges. Her role also involves contributing to multidisciplinary team discussions and responding to urgent situations.
Leona said: “I want parents and carers to know there is someone outside of the clinical ward who can advocate for them. I am here to train staff and also learn from mistakes to see what we can do better.”
Almost 10 years after joining UHCW, Leona describes the position as her ‘dream job’ after spending time working in Paediatrics. Carers Paul and Connie have already seen the positive impact she has had in helping their loved one feel more supported.
Connie said: “I cannot say how vital she is. We are so grateful. She has made a bond with our lady. It means an awful lot.”
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