Overview

• Senior coroner Penelope Schofield found that mental health services failed to manage Nunn's risk, including neglecting to review her care plan after a prior suicide attempt.
• Nunn ordered a lethal chemical online in November 2022, disclosed her intent to a support worker, and received a police visit, yet no long-term safeguarding measures were implemented.
• Systemic shortages of British Sign Language interpreters hindered Nunn's care and delayed her inquest, raising concerns about accessibility for deaf individuals in crisis.
• The coroner announced plans to issue a 'prevention of future deaths' report to multiple government departments, urging systemic reforms in mental health and accessibility services.
• Nunn's family described her death as 'avoidable,' calling for accountability and action to prevent similar tragedies for other deaf individuals facing mental health crises.