A depressed dad-of-one turned himself into a fireball just an hour after his desperate family begged doctors to admit him to hospital.

Now Bradford coroner Roger Whitaker is calling for the Government to change the law and speed up the the system that gets mental health patients help.

Mr Whittaker, who is writing to health minister Alan Johnson and chief medical officer Sir Liam Donaldson, said he believed 28-year-old Jonathan Brannan’s death would have been prevented if there had not been a delay in getting him assessed by a community psychiatrist nurse.

Mr Brannan, who had been suicidal before and had threatened to set fire to himself, was waiting to be assessed when he went out into the garden of his mother’s home in Wyke and poured paint thinners over his head, igniting himself with a cigarette lighter.

Yesterday Mr Whittaker recorded a verdict of “suicide to which neglect contributed”.

He said: “The tragedy is that ten years ago the doctor could have arranged for him to be admitted to hospital. I believe had this still been the case, Jonathan’s death would have been prevented. The situation now is that doctors have to refer first for further assessment from a community psychiatric nurse and this was not possible to happen in such a short time.

“I will be writing to make it clear that here was a preventable situation and that urgent action needs to be secured on a national level so that others in similar situations may not be left in limbo like Jonathan was.”

Mr Whittaker described the current system as “cumbersome” and said although hindsight was a wonderful thing, if the procedures were changed back to the old way, the inquest would not have had to happen.

“This is a case where there was an opportunity that if he had been treated further, this tragedy would not have happened.”

Mr Brannan’s mother Lynne Brewerton, 54, of St Mary’s Crescent, said she was relieved the coroner was taking Jonathan’s case to the top.

She said: “I just hope he is listened to because no one listened to us. We begged for Jonathan to be taken into Lynfield Mount [psychiatric unit] that day but had to wait for someone else to assess him first. The system let my boy down.”

Miss Brewerton said just before Jonathan torched himself he had told her he wanted to be with his dead grandmother. She said: “I checked his pockets to make sure he wasn’t going to overdose on his medication and he said he was going to sit on the wall outside. I went to make a cup of tea and then his dad who was in the front room looking out of the window shouted he was on fire. He’d looked his dad straight in the eye and poured thinners over his head. He lit it and went straight up, all I could see was black smoke. I ran out and he was all curled up.”

A neighbour had rushed to help and got Jonathan into the kitchen while his mum rang the fire brigade who gave first aid until paramedics came.

He was taken to Bradford Royal Infirmary where he was treated for 28 per cent burns to his body, initially not believed to be life-threatening.

However, he was later transferred to Pinderfields Hospital in Wakefield where he deteriorated and was put on a life support machine.

“The doctors told me he would probably be brain damaged even if he did come round. Switching off his life support was the cruellest thing that has ever happened to me. No parent should have to do that,” said Miss Brewerton.

Jonathan died on March 3.

She said her son had been easy-going as a child but problems began when he started drinking at about 14 and started to retreat to his room at night drinking eight cans at a time.

“He hated drugs, never touched anything except for his prescribed medication but he did drink. He wanted to go to Lynfield Mount, he’d been in there before and didn’t like it but he knew at least he would be safe there. I would still have had my boy today if the doctor could have got him admitted straight away but now all I have left is his photo to talk to.”

Miss Brewerton said her son had been “tipped over the edge” after being beaten up a few days before he set himself on fire: “He’d been doing okay until a relationship ended and he came home to live about a year ago. He started drinking again, although he hadn’t been drinking that day, he was upset and frightened about being threatened by local thugs. When he died he had a footmark on his face and a black eye. He was fed up, he was frightened and wanted help but never got it.”