"Failure by mental health services" to manage deaf TikTok star's risk before her death, inquest concludes
Imogen Nunn, who raised awareness of hearing and mental health issues on social media, was found dead in her flat in January 2023
An inquest into the death of "profoundly deaf" TikTok star from Brighton has concluded that there was a "failure by mental health services" to manage her risk.
Imogen Nunn - known as "Immy" - was found dead in her flat on New Years Day 2023, having taken a "substance".
Senior Coroner Penelope Schofield said that failure to put in place an appropriate care plan, safeguarding measures and arrange a face-to-face mental health appointment contributed to her death.
She added her conclusion "is on a background of systemic longstanding and well-documented challenges in the provision of mental health for death 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'e in crisis."
The 25-year-old - described by family as a "rainbow", with a "special aura", was born deaf, and raised awareness of hearing and mental health issues on her social media accounts, which attracted more than 780,000 followers.
Speaking at the inquest today, Immy’s mother, Louise Nunn said: “Our family has been totally devastated by the loss of our beloved Immy - the most gentle, kind and caring young lady you could ever wish to meet. Immy was our rainbow - she would make you feel so special whenever she was around and her heart was filled only with love.
“Despite her troubles in recent years, we never gave up hope that Immy would have the best life possible and get the help she desperately needed. Tragically, that never happened, which is why we are here today.
“We welcome the coroner’s findings, and hope that the agencies concerned can learn vital lessons from what happened to Immy to ensure that no other family has to endure the pain that we have endured.
“We believe Immy’s death was avoidable and that there were several opportunities to help her which were missed by those entrusted with her care. We believe that had appropriate actions been taken after the many times Immy asked the care professionals she trusted for help, she would still be alive today.
“It is clear to us that Immy didn’t want to die and was in fact calling out for and trying her best to get help. But in the end, after fighting for so long for support, she was simply too exhausted to carry on.
“After she died, Immy received thousands of messages from her followers to let us know how she had helped them with their problems, and in some cases even saved their lives. Whilst nothing can ever heal the pain of losing Immy, we take comfort in the knowledge that she was able to help so many others facing similar struggles to her. We believe this will be a lasting legacy for our beautiful Immy who will always be with us in our hearts.”
The inquest resumed at West Sussex Coroner's Court after a two month adjournment due to no British Sign Language interpreters being available to translate for two deaf witnesses.
Coroner: "Shortage" of BSL interpreters "not unique to mental health cases"
The coroner called on the National Register of Communication Professionals working with Deaf and Deafblind People (NRCPD) to give an insight into the impact that failing to provide appropriate communication has on a deaf person.
The coroner said: "Following part of the evidence that we've heard, it became apparent that there was a shortage of BSL interpreters available at times when Immy was in crisis.
"It became apparent that this isn't just a local issue, that this is a national problem."
She added: "It became very, very apparent to me that this shortage wasn't just unique to mental health cases, there were much wider implications."
The coroner also advised that sign language is taught in schools.
"Inconsistencies" in provision of interpreters
Various reports since 2014 have showed that deaf people experience significant health disparities and "nothing really has changed" and the the deaf community still feels it is "ignored".
Report author Theresa Thomas-Morton, the NRCPD chief executive who has 25 years experience as a registered sign language interpreter, told the inquest that there may be "isolated cases where trusts have really worked hard" to make a difference, but added:
"There are still inconsistencies in provision of interpreters in health appointments.
"There hasn't been significant improvement in terms of information regarding health or engagement with the deaf community around their health, or health improvements, or improving their lived outcomes."
More sign language interpreters and communication professionals are needed but there are also "systemic issues" which make it difficult for interpreters to be assigned to bookings, "especially at late notice and especially in a crisis situation", she said.
"Serious implications around safety, dignity and wellbeing" , says report
Framework agreements and the contracts made with agencies that provide interpreters are among the issues standing in the way of provision being available when needed, the court heard.
Pay and whether the interpreter is given adequate information before attending an assignment are other challenges.
In her report Mrs Thomas-Morton suggested "the lack of availability of a BSL interpreter has serious implications around safety, dignity and wellbeing".
She said a deaf person needs sign language to help make sense of abstract information that someone who is hearing can take for granted, which could force them to make assumptions or to miss lip reading patterns.
Mrs Thomas-Morton said: "I can imagine that that is incredibly exhausting and also quite distressing when you're already in a place of mental health crisis."