Inquest finds failings by Sussex mental health services contributed to the death of 25-year-old TikTok influencer Imogen Nunn

Imogen, known as Immy, died at her flat in Brighton on 1 January 2023 after taking a substance she had ordered online.

Immy, originally from Bognor Regis, had around 800,000 followers on TikTok where she posted videos about being deaf and her mental health. She was profoundly deaf, had struggled with her mental health since the age of 14 and spent several prolonged periods as an inpatient in mental health hospitals.

In her conclusion to the inquest on Friday 23 May, the Senior Coroner for West Sussex, Brighton and Hove, Penelope Schofield found that a series of failures in the care provided to Immy by SPFT mental health services contributed to her death.

The coroner also found that there are systemic, longstanding and well documented challenges in the provision of mental health services for deaf patients and a national shortage of BSL interpreters, which makes it difficult for deaf patients to communicate their distress when their mental health is deteriorating, or they are in crisis.

The failures in the care provided to Immy by SPFT mental health services which were found to have contributed to her death included:

• 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 a suicide forum, and had disclosed that she had purchased a substance online
• Failing to have a face-to-face appointment with Immy on 30 December 2022 to assess her risk.

The inquest heard how, from September 2021 to the time of her death, Immy lived in a flat in Brighton where she was helped by support workers from Venture People. She also received ongoing care and treatment from both a specialist Deaf Adult Community Team (DACT) at South West London and St George’s Mental Health NHS Trust (SWLSG), and Sussex Partnership NHS Foundation Trust (SPFT), where she had a care coordinator and consultant psychiatrist.

In their evidence, Immy’s parents Louise and Ray Nunn told the hearing they believe mental health professionals involved with Immy’s care did not take appropriate steps to support her from July 2022 onwards when she was significantly declining and disengaging with services meant to support her.

The inquest at West Sussex, Brighton and Hove Coroner’s Court in Horsham heard evidence related to the family’s concerns over Immy’s care, including:

• On 23 November, when Immy seems to have reached a crisis point and asked for help and explained a plan to die by the method she eventually did, appropriate support does not appear to have been provided in response.
• Following a welfare visit by Sussex Police in November, without a BSL interpreter, there was a lack of urgency and appreciation of the seriousness of the situation by mental health professionals, who do not appear to have met with her until at least several weeks afterwards.
• On 29 December, when Immy again contacted professionals to explain she was in crisis, unable to keep herself safe and wanted to be admitted, she was left alone at A&E, and the SPFT plan for follow up the next day was not followed.  

On 30 December Immy again told her psychologist that she did not feel safe and had a plan to kill herself by drinking the poisonous substance which she eventually took. She agreed to be admitted to a mental health facility in order to keep herself safe. Despite this, her care co-ordinator did not meet with Immy that day as planned, the admission never happened and there was no referral to any other service which may have helped while in crisis. The coroner found that this was a failure to manage her risk. Immy died in the early hours of 1 January 2023 after taking the poisonous substance she had ordered online.

The coroner ruled that Article 2 of the European Convention on Human Rights (ECHR), the right to life, was engaged by the inquest because she considered that Immy's human rights may have been breached before her death.

The inquest, which began on Monday 17 March, had to be adjourned on Wednesday 26 March because there were no British Sign Language (BSL) interpreters available to attend the hearing, meaning deaf witnesses were unable to give evidence. The inquest resumed on Tuesday 20 May, when BSL interpreters had been booked, and concluded on Friday 23 May.

When adjourning the inquest in March, the coroner issued a separate Prevention of Future Deaths (PFD) report raising concerns over the lack of availability of BSL interpreters available to deaf mental health patients like Immy and also wrote to the Justice Secretary to highlight her concerns about the impact of this issue on court proceedings. The PFD report was sent to the Department of Health and Social Care, NHS England, the National Register of Communication Professionals working with Deaf and Deafblind People, the disability minister Stephen Timms and Cabinet Office Minister Nick Thomas Symonds. Copies were also sent to the British Deaf Association and the National Deaf Children’s Association.

At the inquest conclusion the coroner said she will issue further PFD reports to raise concerns about the systemic issues faced by deaf people. She will issue the reports to 4 government ministers: the Cabinet Office, the Department of Work and Pensions, the Department of Education, and the Department of Health and Social Care. The coroner expressed her hope that that ministers will listen and that there will be changes made.

Immy’s parents Louise Sutherland and Ray Nunn were represented at the inquest by solicitor Caleb Bawdon with Olivia Fletcher at law firm Leigh Day and counsel Tom Beamont at 1 Crown Office Row.

Speaking after the conclusion to the inquest, 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 family’s solicitor, Leigh Day’s Caleb Bawdon said:

“Immy’s family welcome the coroner’s findings that Immy was let down by those entrusted with her care.

“Throughout this inquest we have heard evidence detailing a series of failings by those responsible for caring for her.

“Her family firmly believe her death was avoidable and that, had the mental health care professionals taken the appropriate steps to support her in the months leading up to her death, she would still be alive today. 

“Immy’s family have been devastated by the loss of their beloved daughter yet, throughout this inquest process, they have remained determined to ensure that vital lessons are learned from her death.

“This includes when this inquest had to be adjourned for two months due to a lack of availability of British Sign Language interpreters to enable deaf witnesses to give their evidence. To have had their daughter’s inquest disrupted by the very same issue Immy repeatedly faced herself, has been bitterly disappointing and upsetting for her family.

“Immy’s family have welcomed the coroner raising concerns over this issue to Government ministers and other official bodies, and trust that urgent action will be taken so no other family has their loved one’s inquest disrupted in this way again.

“The coroner concluded that deaf mental health patients like Immy face systemic, longstanding and well documented challenges in accessing treatment they need. Despite over a decade of clear evidence, these barriers to deaf patients accessing healthcare remain.

The family are now calling on all the agencies that were responsible for Immy’s care – and those who the coroner believes have the power to take action – to make sure the voices of those using mental health services are heard and properly acted upon in order to avoid a repeat of this tragedy in future.”