TikToker died after 'failure' by health services

A coroner has 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 on New Year's Day 2023 having struggled with her mental health since she was 13.

On Friday, the inquest at West Sussex Coroner's Court in Horsham heard proper safeguarding measures were not put in place after Ms Nunn told a nurse she had bought chemicals online for use in suicide.

Sussex Partnership NHS Foundation Trust apologised that it did not deliver "consistent quality care" and said its care planning, management of risk and communication with other NHS organisations should have been better.

Senior coroner Penelope Schofield said there was a "failure" from mental health services to manage Ms Nunn's risk by not reviewing her care plan after she tried to kill herself in October 2022.

She said there was also a failure to put in place safeguarding measures after being told Ms Nunn had accessed a pro-suicide website, and to have a face-to-face meeting to assess her risk two days before her death.

The coroner also underlined a backdrop of "systemic challenges" with the number of British Sign Language (BSL) interpreters across various UK industries and indicated she would be writing to the government about this.

Ms Schofield 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."

• If you have been affected by any of the issues raised in this story you can visit BBC Action Line.

The court previously heard Ms Nunn contacted her support worker at the deaf adult community team on 23 November 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, she 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.

On the same day she also sent a message to her therapist saying: "I want to be admitted to hospital I can't keep myself safe."

No BSL interpreter was taken to the meeting as there was not enough time to arrange one, the court heard.

Louise Nunn, Ms Nunn's mother, said: "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."

Ms Nunn, who was born deaf, raised awareness of hearing and mental health issues on her social media accounts, which attracted more than 780,000 followers.

Her mum said: "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."

The inquest into Ms Nunn's death had to be adjourned for two months in March because there were no BSL interpreters available to translate for two deaf witnesses.

Ms Schofield has proposed to write to the Cabinet Office, the Department for Education, Department for Work and Pensions and the Department of Health and Social Care about the "systemic" issues underlined by the inquest.

The Sussex Partnership NHS Foundation Trust said: "Since Immy's death we have improved how we audit the quality of documentation, including care plans and risks assessments.

"We are introducing a new electronic patient records system, which will improve our ability to share information with other NHS partners.

"We are committed to working with all partners to improve accessibility to BSL interpreters and will support any changes arising from the concerns raised by the senior coroner."

Additional reporting from PA Media.

Follow BBC Sussex on Facebook, on X, and on Instagram. Send your story ideas to [email protected] or WhatsApp us on 08081 002250.