The coroner, Dr William Dolman, made a recommendation to report the circumstances of the inquest to the Home Secretary after hearing that Turan Pekoz, an asylum seeker, set himself alight in desperation at being separated from his family in Turkey for three years.
Mr Pekoz, 43, poured petrol over his head and upper body during an interview at the Quest House immigration office on 12 March. He suffered 28 per cent burns to his head and upper body and died from shock four days later in the burns unit of Queen Mary's hospital, Roehampton.
Nigel Lamond, the immigration officer who had been conducting the interview, said that as it began Mr Pekoz had refused to sit down and began shouting in Turkish to his interpreter. He then took an Evian bottle containing yellow liquid from his pocket, which Mr Lamond believed was urine to be thrown as a protest. Instead, Mr Pekoz poured the liquid over his head and body before igniting it with a lighter.
Cezmi Yurdagal, Mr Pekoz's interpreter, said: 'He was shouting that he wouldn't have been here if he hadn't had problems. He said, 'Why are you doing this to me?'. '
He said that Mr Pekoz, engulfed in flames, then opened the door and walked into the waiting area before entering another room where an interview was taking place.
Elizabeth Batha, an articled clerk, said: 'He came into the interview room, he was shouting and he had his hands out in front of him completely in flames. I didn't see anyone attending to him then. He was right next to us, he stood in the doorway, nobody could leave the room.'
She said: 'There was a fire extinguisher but it was not until we had hunted around that someone found it.' Because of the delay, Ms Batha said, people were pouring cartons of water from a nearby drinking fountain over Mr Pekoz to try to put the fire out. With the help of an extinguisher they eventually succeeded.
Mr Pekoz was still shouting after the fire was put out. Another witness, Seda Kervanoglu said: 'He was just standing there, shouting, 'What sort of human rights do you have, I am going to condemn this to the whole world.' ' Mr Pekoz went into a coma soon afterwards.
The dead man's son, Mehmet Pekoz, 19, gave evidence through an interpreter that his father was depressed at being separated from his family. He said he did not think his father had wanted to kill himself. Caroline Bowman, who was representing the family, said this was to have been a very desperate protest with unforeseen tragic consequences.
The coroner recorded a verdict of death by misadventure.