A father-of-five set himself on fire in Houghton Regis in a suicide bid and died nine hours later in hospital, an inquest heard.
47-year-old Clinton Comb set himself alight at around 1pm on June 25 last year at a wooded area off Parkside Recreation Ground.
After being airlifted to a specialist burns unit at Broomfield Hospital in Essex, Mr Comb later succumbed to his injuries at 10pm the same evening.
It was understood by emergency services that several passers-by helped to extinguish the flames before their arrival.
Mr Comb was found to have 95% full thickness burns and his injuries were deemed to be “non-survivable”.
After being transferred to Broomfield Hospital, clinicians focused on providing pain relief and end-of-life care until his death.
Mr Comb’s sister attended the inquest and gave evidence in relation to her brother’s treatment at the Ash Ward mental health unit at Luton & Dunstable Hospital.
She stated that his medication packet had later been found to be empty, having run out on June 21 just one day after his release.
A subsequent serious incident review identified four care delivery problems from East London Foundation Trust – responsible for mental health services in the area – including poor communication with Mr Comb’s family.
A conclusion was given of suicide after intentionally setting himself on fire.