Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0267, written 14 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 May 2026 |
|---|---|
| Reference | 2026-0267 |
| Deceased | Natalia Cestaro |
| Coroner | Linda Lee |
| Coroner area | Coventry and Warwickshire |
| Organisation named | Coventry and Warwickshire Partnership NHS Trust |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1. THIS REPORT IS BEING SENT TO 1. Chief Executive, Coventry and Warwickshire Partnership NHS Trust (CWPT) 2. Chief Executive, University Hospitals Coventry and Warwickshire NHS Trust (UHCW) 2. CORONER I am Linda Lee, Acting Area Coroner for Coventry and Warwickshire. 3. CORONER’S LEGAL POWERS I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 4. INVESTIGATION AND INQUEST The investigation into the death of Natalia Violet Cestaro (known as “Tali”), aged 18, who died on 15 November 2023 at University Hospital Coventry & Warwickshire, was opened on 28 November 2023 and concluded on Friday 1 May 2026. 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 5. CIRCUMSTANCES OF THE DEATH , one of and was transferred to was removed endoscopically. During the procedure a Natalia Violet Cestaro (“Tali”) was an inpatient under the care of Coventry and Warwickshire Partnership NHS Trust with complex mental health needs and a known history of impulsive ingestion of foreign objects. During the same admission in September 2023, she had previously ingested which was removed endoscopically and the other surgically. On 5 November 2023, Tali ingested a University Hospitals Coventry and Warwickshire NHS Trust for endoscopic removal. The 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. 6. MATTERS OF CONCERN In my opinion, the following matters give rise to a concern that there is a risk of future deaths. 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. 7. ACTION In my opinion, action should be taken to prevent future deaths, and I believe your organisations have the power to act. 8. RESPONSE You are under a duty to respond to this report, setting out what consideration you have given to the concerns raised, namely by [date].(assuming this goes out tomorrow it is 56 days from that date -9 July 2026) 9. COPIES A copy of this report is being sent to the Chief Coroner. It may be published on the judiciary website. It is also being sent to the following Interested Persons: (cid:127) The family of the deceased Linda Lee Acting Area Coroner for Coventry and Warwickshire 14 May 2026
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
9 July 2026 Ms Linda Lee Acting Area Coroner for Coventry and Warwickshire Cheylesmore Manor House, Manor House Drive, Coventry, CV1 2ND Dear Ms Lee, Re: Inquest touching the death of Ms. Natalia Violet Cestaro – Response to Regulation 28 Report. I am writing in response to the Regulation 28: Prevention of Future Deaths Report issued following the inquest into the death of Ms. Natalia Violet Cestaro and received by the Trust on 14 May 2026. I am grateful for the careful consideration you have given during the inquest process and have reflected fully on the concerns raised within the Prevention of Future Deaths Report. We recognise the significance of these concerns and the responsibility placed upon us to identify learning, strengthen our systems and processes, and take meaningful action to reduce the likelihood of similar events occurring in the future. Throughout the inquest, we were pleased to assist the Court by providing evidence regarding both Natalia's care and the improvements already underway across our services. The concerns identified have been carefully considered within the context of our broader patient safety and quality improvement agenda, and we welcome the opportunity to provide assurance regarding the actions taken in response. You identified three specific areas of concern, which I address below. 1. Proactive scope of risk assessment for impulsive ingestion (CWPT) As part of the learning identified through the review of Natalia’s care and treatment, we recognised the need for more consistent assessment of impulsivity as a contributory risk factor, particularly where self-harm or suicide risk has been identified. - Coventry and Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY We will continue to undertake daily environmental audits across our mental health wards to identify, address and remove potential and foreseeable hazards. These audits are completed electronically, updated in real time and enable immediate escalation of environmental concerns requiring Estates intervention. Our safety (risk) assessment, formulation and planning framework has undergone multidisciplinary review to ensure alignment with National Institute for Health and Care Excellence (NICE) Guideline NG225. The framework incorporates a formulation-based approach that considers factors which may predispose individuals to unsafe behaviours, perpetuate risk, or act as protective influences. Impulsivity is specifically considered within this formulation process. This approach supports a more comprehensive exploration of dynamic triggers, access to means, decision-making capacity, protective factors and the function of harmful behaviours, enabling appropriate risk mitigation measures to be implemented promptly. The resulting safety plan promotes a person-centred, strengths-based approach that empowers individuals to manage their own safety, with appropriate support from clinical teams. Our training programme supports this formulation-based approach to safety and risk management, with a strong emphasis on professional curiosity, multidisciplinary collaboration and triangulation of information obtained from those important to the individual and those involved in their care. The training encourages staff to consider a broader range of factors that may influence safety and wellbeing and supports a move away from historical documentation and approaches, such as the Skills-based Training on Risk Management (STORM) and Working with Risk (WWR) tools. The quality of risk assessments is routinely monitored through our Audit Management and Tracking (AMaT) system. Audits are undertaken by ward management teams, with additional assurance provided through separate Matron- led audits. 2. Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW) We acknowledge the importance of robust communication arrangements and the need for clear, agreed transfer processes between acute and mental health services. As part of the Safety Improvement Plan accompanying the Patient Safety Incident Investigation (PSII) report, an action was agreed to develop a Standard Operating Procedure (SOP) to provide guidance on communication, care and treatment arrangements for patients open to our services who are conveyed to University Hospital Coventry and Warwickshire (UHCW). Page: 2 of 4 CWPT and UHCW are signatories to a Memorandum of Understanding (MoU) setting out arrangements for patients receiving inpatient mental health care who require physical healthcare treatment within a local acute hospital setting. Escalations during core hours (Monday to Friday, 08:00–17:00) are managed by the Clinical Matron or a nominated deputy. Out-of-hours and weekend concerns are managed through established on-call arrangements. Compliance with the MoU is subject to monthly monitoring, with the frequency of review to be reconsidered after six months, informed by performance data and escalation trends. The MoU is supported by the SOP, which clearly sets out staff responsibilities when a patient requires transfer to an acute hospital, whether as an emergency or as part of planned care and treatment. It also outlines the responsibilities of the respective care teams and includes a checklist that accompanies patients returning from the acute setting to one of our mental health wards. 3. Assurance and auditing of expected communication processes (CWPT) Adherence to the SOP will be embedded within ward safety huddles, team handovers and ward governance processes. Oversight is maintained through daily assurance meetings involving Matrons. Outcomes from these meetings inform the Trust’s twice-daily Operational Pressures Escalation Level (OPEL) calls, ensuring organisational awareness and timely escalation where required. Any individual care concerns or communication issues identified will be managed through local incident reporting processes and subject to review in accordance with the Trust’s incident management framework. Learning identified through these reviews will be used to inform ongoing procedural improvements and workforce education and training requirements. In addition, compliance with the agreed communication and transfer processes will be monitored through local governance arrangements, providing assurance that expectations are understood, consistently applied and embedded within routine practice. Any themes or trends identified through this monitoring will be escalated through the Trust’s governance structures to support continuous improvement and organisational learning. I trust this response provides assurance that we have carefully considered the concerns identified by the Court and have taken proportionate and meaningful action to address them. The measures outlined above form part of our wider commitment to strengthening patient safety, improving partnership working, and ensuring robust governance and oversight of care delivery. While we recognise that no single intervention can eliminate risk entirely, we remain committed to embedding the learning arising from Natalia's death across our Page: 3 of 4 services and to continuously reviewing the effectiveness of the actions implemented. We are grateful for the opportunity to reflect on the findings of the inquest and will continue to work collaboratively with partner organisations to improve the safety and quality of care for the people who use our services. Yours sincerely, Copy to: , Chief Executive Herefordshire and Worcestershire. , Chief Nursing Officer, NHS Coventry and Warwickshire and NHS Warwickshire NHS Trust. , Chief Executive, University Hospitals Coventry and Page: 4 of 4
NHS University Hospitals Coventry and Warwickshire NHS Trust Clifford Bridge Road Walsgrave Coventry CV2 2DX www.uhcw.nhs.uk 8 July 2026 Ms Linda Lee Acting Area Coroner for Coventry & Warwickshire Coroner's Office Manor House Drive Coventry CV1 2ND Dear Ms Lee Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS (Natalia Cestaro) Thank you for your correspondence following your investigation into the death of Natalia Cestaro, (Tali), who sadly died on 15 November 2023 at University Hospital. I write in response to the matters of concern outlined in the Prevention of Future Deaths (Regulation 28 report dated 14th May 2026), specifically the particulars outlined in (b) which seek assurances in relation to interface working and liaison between UHCW as the acute provider, and CWPT as the mental health provider. In response I can confirm that we have agreed the content of a Memorandum of Understanding (MOU) with CWPT (copy attached). The MOU seeks to bring clarity to roles and responsibilities for those circumstances in which an inpatient mental health patient may be admitted to UHCW for the treatment of a physical health condition This MOU document describes a shared working arrangement that seeks to ensure that patients are transferred to UHCW with all of the relevant information required about their mental health condition such as care plans, risk profile information and management plans to continually support mental health care and treatment alongside the treatment required to meet the patients physical health care needs. This MOU is further supported by a Standard Operating Policy developed by CWPT and shared with UHCW (also attached) which outlines processes that will be followed when a patient is transferred to UHCW The MOU and the SOP process will be subject to routine monitoring to provide assurances re: compliance (as described with Section 6.3 of the MOU and Section 8 of the SOP document). Where challenges arise in the management of any in-patients transferred to UHCW from CWPT this will be escalated (in hours) to the CWPT clinical matron for the service area or nominated person in their absence and where required through the established daily system calls that take place between senior clinical leaders (UHCW and CWPT). Out of hours any matters of concern can be escalated through the established on-call arrangements (24/7). I hope this response outlines the agreements we have reached and provides assurances that changes have been made to improve the interface working arrangements between UHCW and CWPT so that we can provide the best care that we can to those patients who need to receive care for a physical health condition at UHCW alongside mental health in-patient treatment. Yours sincerely Chief Executive Officer 2
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