An inquest revealed that a teenager, known as Tali, could have been saved if medical professionals had acted sooner. Tali, who had autism and emotionally unstable personality disorder, was under the care of Coventry and Warwickshire Partnership NHS Trust at the Caludon Centre.
She had a history of swallowing foreign objects impulsively. In September 2023, Tali ingested an item that was removed through endoscopy. Despite doctors suspecting a stomach wall tear during the procedure, no further action was taken. Subsequently, Tali experienced escalating pain before her condition deteriorated.
Diagnostic imaging was scheduled but not conducted as planned, and the surgical team was not informed of her condition. By the time the gastric perforation and sepsis were identified, it was too late to save her.
Tali’s family described her as bright and outgoing, with a passion for musicals and cooking. She was supportive of others facing similar challenges and shared her experiences on Instagram.
The coroner’s report highlighted failures at the NHS Trust and University Hospitals Coventry and Warwickshire NHS Trust. The delay in recognizing and addressing Tali’s deteriorating health was noted as a contributing factor to her death.
Both trusts acknowledged the findings and outlined improvements made in patient safety and support. Mental health support services were also emphasized for those in need.
The UHCW NHS Trust expressed condolences to Tali’s family, stating that changes had been implemented following a patient safety review. Collaborative efforts with the Coventry and Warwickshire Partnership Trust were ongoing to enhance care for patients with complex mental health needs.
The Coventry and Warwickshire Partnership NHS Trust accepted the inquest findings and detailed improvements in safety planning and support for patients in acute services. They committed to learning from the case and enhancing the quality of care provided.
For individuals struggling with mental health issues, support services in Coventry and Warwickshire are available 24/7 by calling 111. In case of emergencies, calling 999 or seeking immediate assistance was recommended.
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