Imogen Nunn, 25, who was born deaf, died after ingesting the product on New Year’s Day 2023.
An inquest into her death started last week and was adjourned today (Wednesday).
Her family have been told they will have to wait another two months before the inquest can be resumed to take evidence from her deaf friends.
Senior Coroner Penelope Schofield took the highly unusual step of issuing a call for action during the inquest.
The Prevention of Future Deaths report – which would usually be issued after an inquest – has been sent to the Dept of Health and NHS England.
A letter of concern has also been sent to the Ministry of Justice.
It is understood West Sussex coroner’s officers made more than 500 phone calls trying to locate a British Sign Language interpreter for the inquest.
The first deaf witness was stood down on the second day of the inquest when no interpreter could be found to attend the coroner’s court in Horsham.
Ms Schofield told the family today (Wednesday) the examination of the circumstances of Immy’s death was being adjourned without confirmation an interpreter could be found.
The earliest the inquest will resume is May 20.
During the last day of sitting with only hearing witnesses, the coroner told Immy’s family she deeply regretted having to adjourn for at least two months.
“I’ve been put in a difficult position with the two deaf witnesses.
“With the difficulties this court faces, we have all got to work together.
“The priority is the inquest conclusion for the families.
“My only regret at this stage is that I cannot confirm to the family we have an interpreter in place for the resumed hearing.
“It is with the deepest regret this case is being adjourned.
“We cannot have other families going through this.
“It’s quite ridiculous,” Penelope Schofield said.
Immy Nunn’s family expressed their continued distress and praised the action taken by the coroner.
Mother Louise Nunn said: “We welcome the coroner taking the highly unusual step of issuing a PFD report during the inquest to highlight the chronic lack of availability of BSL interpreters.
“The coroner has rightly recognised that without a BSL interpreter, it would not be possible for the deaf witnesses to give their evidence to the inquest.
“Immy’s first language was BSL and sadly this is an issue she faced on countless occasions, including when trying to engage with the services meant to support her.
“To be in the position where there is no option but to adjourn the inquest into her death as a result of the same issue is hugely upsetting and disappointing to us.
“We are now calling for urgent action in response to the coroner’s concerns, so that no other family has to have their loved one’s inquest disrupted in this way in future.”
The Coroner’s PFD report states: “During the course of the Inquest (which has yet to be concluded) I heard evidence that there was a lack of availability of British Sign Language Interpreters able to help support Deaf patients in the community who were being treated with mental health difficulties.
“This was particularly apparent when mental health staff were seeking an interpreter at short notice for a patient who was in crisis.
“The lack of interpreters available has meant that urgent assessments are being carried out with no interpreters present.
“The overall lack of British Sign Language Interpreters has also meant that this inquest has itself had to be delayed/adjourned for two months due to there being no available interpreters to interpreter for two deaf witnesses over the two week period of the inquest.”
The inquest was told Sussex Police had a number to call for interpreters.
Officers were not sure if any of them were trained in BSL.
Imogen Nunn used TikTok to raise awareness of hearing and mental health to more than 780,000 followers.
The inquest is scheduled to resume on May 20.
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