TikTok star died after ‘failure’ by mental health services, inquest finds
Imogen Nunn, 25, raised awareness of hearing and mental health issues on her social media accounts
A coroner flagged “failure by mental health services” to manage the risk to a deaf TikTok star who died after ingesting a poisonous substance she ordered online.
Imogen Nunn, 25, died in Brighton, East Sussex, on New Year’s Day 2023, having had struggles with her mental health since she was 13.
Ms Nunn was born deaf, raising awareness of hearing and mental health issues on her social media accounts, which attracted more than 780,000 followers.
On Friday, the inquest at West Sussex Coroner’s Court in Horsham, heard that proper safeguarding measures were not put in place after Ms Nunn told a nurse she had bought chemicals for 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.
“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 underlined a backdrop of “systemic challenges” with the number of British Sign Language interpreters across various UK industries and has indicated she will be writing to multiple 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) earlier told the inquest that failing to provide proper translation for deaf people could amount to a breach of human rights.
In light of this, Ms Schofield found an “arguable breach” of Article Two, and has commissioned a second “prevention of future deaths” report.
“Immy’s death underscores these systemic challenges,” she added.
The court previously heard Ms Nunn ordered a lethal chemical substance online on November 14, which was delivered to her home address on November 21.
She had contacted her support worker at the deaf adult community team on November 23 and told them she had “bought something online that she planned to take to end her life”.
While the police were contacted, and they visited Ms Nunn’s address, no long-term changes were made to her care plan, the inquest heard.
Three days before Ms Nunn’s death, on December 29 2022, Ms Nunn received a check-in visit at her home from care professionals, after sending a text message saying she had had an increase in suicidal thoughts.
She had also sent a message to her therapist saying “I want to be admitted to hospital I can’t keep myself safe”, the same day.
No BSL interpreter was taken to the meeting as there was not sufficient time to arrange one.
The inquest into Ms Nunn’s death had to be adjourned for two months because there were no BSL interpreters available to translate 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 proposed to write to the cabinet office, the Department for Education, Department for Work and Pensions and Department of Health and Social Care about the “systemic” issues underlined 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.”
If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.
If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week.
If you are in another country, you can go to www.befrienders.org to find a helpline near you.