TikTok star Imogen Nunn’s death linked to mental health service failures and interpreter shortages, inquest

A coroner has found a “failure by mental health services” to manage the risk to deaf TikTok creator Imogen Nunn, who died after ingesting a poisonous substance she ordered online.

Imogen Nunn, 25, passed away in Brighton, East Sussex in the UK on New Year’s Day 2023, following long-term struggles with her mental health since she was 13.

Born deaf, Ms Nunn used her social media platforms to raise awareness about hearing and mental health issues, amassing more than 780,000 followers.

At the inquest at West Sussex Coroner’s Court in Horsham on Friday, it was heard that safeguarding measures were not put in place after Ms Nunn told a nurse she had bought chemicals to use in suicide.

Senior coroner Penelope Schofield said: “There was a failure by the mental health services to manage her risk by failing to review her care plan following a suicide attempt in October 2022,” she said.

“Failing to put in place safeguarding measures following being advised that Immy had accessed the pro-suicide website and disclosed that she had purchased chemicals to use in suicide, and failing to have a face-to-face appointment with Immy on December 30 2022 to assess her risk.”

The coroner also highlighted “systemic challenges” with the shortage of British Sign Language interpreters across UK industries and said she would be writing to several government departments.

The coroner said: “This is on a background of systemic, longstanding and well-documented challenges in the provision of mental health for deaf patients, with particular emphasis on the national shortage of BSL interpreters and the difficulty this presents for patients to be able to communicate their distress when their mental health is deteriorating or they are in crisis.”

An expert from the National Register of Communication Professionals working with Deaf and Deafblind People (NRCPD) told the inquest that failing to provide proper translation for deaf people could amount to a breach of human rights.

Ms Schofield found an “arguable breach” of Article Two and has ordered a second “prevention of future deaths” report.

“Immy’s death underscores these systemic challenges,” she added.

The court heard Ms Nunn ordered a lethal chemical online on November 14, delivered to her home on November 21.

She contacted her support worker at the deaf adult community team on November 23 and said she had “bought something online that she planned to take to end her life”.

Police visited Ms Nunn’s address, but the inquest heard no long-term changes were made to her care plan.

Three days before her death, on December 29, Ms Nunn received a check-in visit from care professionals after texting that she had increased suicidal thoughts.

She also messaged her therapist, saying, “I want to be admitted to hospital I can’t keep myself safe,” that same day.

No BSL interpreter was present at the meeting as there was not enough time to arrange one.

The inquest also had to be adjourned for two months because there were no BSL interpreters available for two deaf witnesses in March.

The coroner also noted “discrepancies” in the note keeping from Ms Nunn’s care co-ordinator Ray McCullagh.

Ms Schofield said: “There were issues around the lack of record keeping from nurse McCullagh.

“I am not going to address each of the occasions where it appears there has been a discrepancy.”

The discrepancies showed a failure in care, but did not undermine the therapeutic relationship in Ms Nunn’s case, the inquest heard.

Ms Schofield has said she will write to the cabinet office, Department for Education, Department for Work and Pensions, and Department of Health and Social Care about the “systemic” issues raised by the inquest.

The coroner thanked Ms Nunn’s family for the “dignity” they showed throughout the process.

“Hopefully some good will come out of this and people will listen and changes can be put into place,” she said.

Remembering her daughter, Louise Nunn said: “Immy was our rainbow – she would make you feel so special whenever she was around and her heart was filled only with love.”