Imogen Nunn Prevention of future deaths report

PFD Report All Responded Ref: 2025-0494
Date of Report 7 October 2025
Coroner Penelope Schofield
Response Deadline est. 2 December 2025
All 1 response received · Deadline: 2 Dec 2025
Sent To
Response Status
Responses 1 of 11
56-Day Deadline 2 Dec 2025
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
I draw to your attention that a previous Prevention of Future death report was issued on 24th March 2025 before the Inquest concluded. This report was issued to the Department of Health and Social Care, NHS England and the National Registers of Communication Professionals working with the Deaf and Deafblind People (NRCPD) It was issued before the Inquest had concluded as it had already become apparent that there was a real lack of British Sign Language Interpreters (BSLs) able to help support Deaf patients in the community who were being treated with mental health difficulties. This was putting this cohort of individuals at risk. The overall lack of British Sign Language Interpreters was also evidenced directly by the Court in that this Inquest has had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf/mute witnesses over the two week period of the Inquest. A joint reponse to this report from Department of Health and Social Care and NHS England has been received. Having heard further evidence in this matter, once the Inquest resumed, I felt compelled to issue a further report. My concerns are
1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023. AND the Minister of State (Minister for Social Security and Disability) The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of

Regulation 28 – After Inquest Template Updated 15/07/2025 TG statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area.
2. Department of Health and Social Care Evidence indicates that clinicians who are fluent in British Sign Language (BSL) provide a significantly better experience for deaf patients compared to non-BSL-speaking clinicians relying solely on interpreters. The NHS England response to the earlier Prevention of Future Deaths (PFD) report outlined the role of Integrated Care Boards (ICBs) in commissioning interpreting services for NHS Trusts. However, there is a clear shortage of BSL-proficient clinicians, and insufficient efforts are being made to recruit and retain these professionals. This gap is failing to meet the needs of deaf individuals.
3. Matter for the Department of Education. Evidence was heard that the lack of BSL interpreters was in part due to the lack of availability of BSL qualifications and training.
Responses
Department for Education
9 Oct 2025
The Department for Education acknowledges concerns regarding BSL interpreter shortages and procurement, but maintains the government's preference for industry self-regulation. The Minister will raise these issues with the BSL Advisory Board to consider ways in which improvements can be made. AI summary
View full response
Minister for Women and Equalities Cabinet Office Office for 70 Whitehall Equality and Opportunity November 2025 HM Coroner Penelope Schofield The Coroner’s Office, Woodvale, Lewes Road, Brighton BN2 3QB ta fliu Sctf_kca, Your ret: 2025-0494 - Imogen Nunn: Prevention of future deaths report Thank you for the Regulation 28 report of 9th October 2025 sent to the Department for Education (DfE), the Cabinet Office and Department for Work and Pensions regarding the death of Imogen Alice NUNN (‘Immy’). lam replying as the Minister for Women and Equalities and Secretary of State for Education and on behalf of the Minister for Social Security and Disability. I would first like to express how saddened I was to read of the circumstances surrounding Immy’s death, and I offer my sincere condolences to her family and friends. The circumstances you describe in your report are concerning and lam grateful they have been broughtto my attention and the attention of my Ministerial colleagues through your enquiries. Through your discussions with NRCPD, the voluntary regulator for language service professionals, you are raising concerns regarding the national shortage of British Sign Language (BSL) interpreters, the procurement process for contracting language services, industry regulation and lack of availability of BSL qualifications and training. In preparing this response, my officials have made enquiries with Crown Commercial Services, the UK’s biggest public procurement organisation and an executive agency of the Cabinet Office, and the Department for Business and Trade. They have also worked with our British Sign Language Advisory Board to ensure we adequately address your concerns. As Minister for Women and Equalities, my role is to promote equality of opportunity for all individuals and to work to reduce disparities. I work with the Minister of Social Security and Disabilities to champion the rights of Deaf and disabled individuals, in line with our manifesto commitment. We engage with a wide range of Deaf and disabled individuals and

organisations and collaborate closely with the Lead Ministers for Disability, who are responsible for championing the interests of Deaf and disabled people in their department. Following the passage of the BSL Act in 2022, the BSL Advisory Board was created to advise the Government on key issues impacting the Deaf community in their everyday life. To address the issues raised by the Deaf community, the Board also established subgroupstofocuson particularpriorities, including health and social care and education. Last week the BSL Advisory Board published a detailed report titled ‘Locked out: Exclusion of deafand deafblind British Sign Language users from health and social care in the UK’. This report is the culmination of 3 years of work, bringing together Deaf and Deafblind people, professionals, and researchers from across the country. The report examines the experiences of Deaf and Deafblind BSL people within the health and social care system, and provides evidence-based recommendations to improve accessibility and inclusion across NHS and social care services. The findings echo some of the issues you have raised
- a workforce shortage of BSL interpreters and ‘patchwork provision’ across the country. It provides numerous recommendations for govern ment departments to address these findings, including giving BSL users greater control over interpreter bookings, the establishment of a national video relay service and issuing guidelines for interpreter provision. It is my hope thatthe evidence presented in this report and its recommendations can provide govern ment departments with a blueprint for improving health and social care service provision forthe Deaf community. Turning to the specific concems you raised, I’ll start by sharing with you details regarding opportunities for individuals to undertake BSL qualifications and training. The DfE is introducing a GCSE in BSL. As well as learning how to sign effectively, theGCSEwill give studentsan understanding of the historyof sign language in the UK. Together, this content should give pupils a broad understanding and appreciation of the language. We hope that the development of this unique qualification creates an important step towards not only fostering greater recognition of BSL as a language, but also encouraging more students to consider developing their skills in this language at a higher level in the future. We are committed to developing a qualification that benefits both students and the wider deaf community. The department has worked closely with subject matter experts to develop the subject contentfor the new qualification, and public consultations have been held overthe years to get us to the current stage. In Novemberthisyear, following a second consultation and detailed collaborative working with organisations and people across deaf and hearing communities, Ofqual, the independent regulator, set out the rules for the assessment of the GCSE. Exam boards are now able to develop detailed specifications which will form the basis of course content

to be taught in schools and colleges. These new regulations mark a further step towards a qualification that could connect communities. With regard to what is currently available for those who want to learn BSL, qualifications are available across several levels
- from BSL Level 1 qualification, ideal for anyone who wants to learn basic language skills through to Level 6, being equivalent to an honours degree and the highest certification. The awarding body Signature is a leading provider of accredited BSL qualifications. To be accredited to become an interpreter, and to register with NRCPD, an individual must have an approved Level 6 BSL qualification or its equivalent. There are funds available for adults who want to learn new skills through our Adult Skills Fund. However, the AdultSkills Fund mainly focuses on lower level skills, so whilstfunding is available (if all the correct criteria is met) for adult learners to study BSL qualifications, the fund only covers adult learners up to level 3 orequivalent. Given that BSL interpretation qualifications are a higher-level qualification, it must be noted that Higher Education (HE) is differentto the otherareas of funding. The Higher Education Sector is autonomous and independentof governmentand sets its own curricula as part of a demand led market. The DfE, through the Strategic Priorities Grant (SPG), provides a large annual grant to the Office for Students (OfS), subject to governmental terms and conditions. For 2024—25 it totalled £1 .456 billion (with £450 million in capital funding over three years). However, we recognise that there is no explicit mention of BSL or BSL-specific funding in the SPG guidance or allocations, so there is no ring-fenced funding for BSL courses at HE institutions. You raised in your report concerns about the lack of availability of BSL qualifications and training. As the above shows, there are routes to achieve the professional qualifications needed to become a qualified interpreter, however I recognise that there are gaps in the funding model that might support this route for some individuals. The BSL Advisory Group’s Education Subgroup has to date prioritised focusing on issues relating to the education of Deaf children. They have supported DfE and Ofqual as part of the BSL GCSE consultations, and earlier this year met with Stephen Morgan MP, the (then) Minister of Early Education to discuss their priorities. I will ask officials in the DfE to consider the issues raised above and to work with the BSL Advisory Board to consider the changes required to enable more individuals to study BSL to a level sufficient to become a BSL Interpreter. I will now address specifically your concerns around the procurement provision for interpreters and industry regulation. Government procurement addresses the need to buy goods and services more efficiently and cost-effectively through its Crown Commercial Services (CCS), a business unit that

utilises its commercial expertise to help buyers in public sector organisations, including govern ment departments and local governments, by providing commercial agreements and procurement expertise. However, their commercial agreements are optional routes to market. A challenge to procuring BSL interpretation lies in the very nature of the fragmentation of the BSL interpreter market, with many interpreters registered as freelance or sole traders and not necessarily affiliated with an agency. With regards to industry regulation, the UK Government’s preference is for industries to self-regulate, in orderto promote economic growth, innovation, and competitiveness by reducing the administrative burden on businesses. This is currently the case for BSL interpreters, where the NRCPD mandates qualifications, standards and continuing professional developmentfor those included on their accredited persons list. For most professions, there is no evidence to suggest that mandated industry regulation would increase the numbers of professionals entering that profession and/or elevate the status of that profession beyond what a non-statutory model of regulation already does. That said, I acknowledge the concerns raised by NRCPD regarding procurement practices and the status of the profession and recognise the need to encourage more professionals into the industry, and I will be raising these issues with the BSL Advisory Board and asking them to work with NRCPD to consider ways in which improvements can be made. I want to thank you for bringing your concerns to my attention and I hope this response addresses them. I will continue to work alongside my Ministerial colleagues, the BSL Advisory Board, Deaf people and their representative organisations, to continue to make tangible improvements for the Deaf commu nity. I am confident that we can take steps towards improving the services provided to those most in need. With all best wishes, Minister for Women and Equalities and Secretary of State for Education
Report Sections
Investigation and Inquest
On 04 January 2023 I commenced an investigation into the death of Imogen Alice NUNN (“Immy”) aged 25. The investigation concluded following an Inquest on 23rd May 2025 The conclusion of the Inquest was:- On 1st January 2023 Immy died at her home address of Basement Flat, 15A, Newmarket Road, Brighton, BN2 3QG Narrative Conclusion On or around the 1st January 2023 Immy consumed . Immy at the time was suffering from a deterioration of her mental health. Whilst the taking of this substance on this day may have been an impulsive risky act it is clear that when Immy obtained the she would have been well aware of the implications of taking this substance and as such, on balance, she appears to have made a deliberate decision to take her own life. However there was a failure by the mental health services to manage her risk by a) Failing to review her care plan following a suicide attempt in October 2022. b) Failing to put in place safeguarding measures following being advised that Immy had accessed the Pro-suicide website and had disclosed that she had purchased chemicals to use in suicide. c) Failing to have a face to face appointment with Immy on the 30th December 2022 to assess her risk. 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.

Regulation 28 – After Inquest Template Updated 15/07/2025 TG
Circumstances of the Death
Immy, was profoundly deaf and used a cochlear implant. She suffered from complex post traumatic stress disorder and mixed personality disorder (with emotionally unstable, anxious and dependent traits). Although Immy could lip read she required a BSL interpreter to assist her mental health practitioners in providing support. Interpreters were not always available (particularly at short notice) and meetings and assessments had to take place without an interpreter present. In the months leading up to her death her mental health had been deteriorating. On the evening of 31st December 2022 Immy left her assistance dog in the care of her parents and attended a party with friends. In the early hours of 1st January 2023 Immy left the party and was reported as a high risk missing person. Police Officers were able to contact Immy at 06:08 on 1st January 2023 and she stated she was safe and well at her home address. Officers have attended her home address to check on her but sadly they found Immy deceased a substance she had bought on line approximately 6 weeks before.
Copies Sent To
South West London & St Georges Mental Health Trust Chief Constable of Sussex Police Venture People South East Coast Ambulance Service NHS Foundation Trust National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD) Brighton and Hove City Council
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.