THE family of a man who burned to death in Croham Hurst Woods are "confused and disappointed" that a coroner decided not to reach an open verdict.
In the days before his death, Anthony Billy told his care worker he owed money to a drug dealer.
Mr Billy's family feared he may have been murdered but spent three years fighting for answers after police told them in the immediate aftermath that he had taken his own life.
They welcomed coroner Selena Lynch's decision to rule out suicide after a four-day inquest, which concluded last Friday.
But Simmone Simpson, Mr Billy's sister, strongly believes the coroner should have recorded an open, rather than narrative, verdict about his death on January 19, 2011.
Mrs Lynch told Croydon Coroner's Court an open verdict might lead some to conclude there was something more to Mr Billy's death. "I have found it wasn't suspicious," she explained. "He died at his own hands."
Ms Simpson said: "For our own peace of mind we needed the state to accept that they had made one mistake - they said it was suicide.
"It was massive [that they ruled out suicide] because it means the investigation was wrong from the beginning. So we're thankful for that.
"However, the family are confused and disappointed with the narrative verdict.
"We hoped the coroner would base her conclusion on facts, not opinion. We cannot be sure of exactly what happened to Anthony, so an open verdict seems to us the only option."
Mr Billy suffered from paranoid schizophrenia and was living in Russell Hill Lodge supported accommodation in Purley at the time of his death. His mental state was said to be "stable" and he had recently spent Christmas with his family, who described him as "extremely well".
However, Mrs Lynch said there were signs in Mr Billy's life that "something was going in the background". He had become less interested in taking part in activities, his "delusions" - including speaking of a "god of fire" - were becoming more frequent and he was regularly asking staff if he could access his money.
Mr Billy, a frequent cannabis smoker, also told his key worker he owed cash to a drug-dealer.
At around 3pm on January 19, he asked the manager of the care home for £5. When the request was refused, he "stormed out".
"Mr Billy left his home and went to a petrol station on Brighton Road, Croydon," Mrs Lynch told the court.
"He purchased a canister and filled it with almost three litres of diesel. He then walked to the woods at Croham Hurst, doused himself in [fuel] and applied a naked flame using a lighter or possibly a cigarette end."
A passer-by called 999 and police, firefighters and ambulance crews were sent, but Mr Billy was later pronounced dead. The lighter and canister were found at the scene.
"Thanks to a thorough investigation we can be satisfied [Mr Billy] died at his own hands," said Mrs Lynch, who added that the remaining question was why.
The coroner suggested a number of potential reasons but reached only one firm conclusion: "All the evidence is that this was completely out of character for him. There was never any suggestion that he would harm himself."
She ruled out that Mr Billy had accidentally lit the fuel with a cigarette.
As to whether he had been killed, as his family feared, she said: "I don't think it was a case of homicide. He wasn't murdered, he died of his own hand."
Mr Billy's family alleged Russell Hill Lodge could have done more to protect him after he raised concerns about a drug debt, but Mrs Lynch said she could find no "causative failure" in the "good" care he received.
The inquest had heard he had told key worker Rebecca Yates about the debt on January 16, but when it was raised with his care coordinator no further action was taken.
Mrs Lynch said even though staff knew Mr Billy owed money for drugs, as he was not willing to talk about it, it was "difficult for them to do anything to help him".
Ms Simpson believes the home should have alerted the police and their failure to do so meant the initial investigation incorrectly concluded Mr Billy had taken his own life.
"We're not looking for someone to blame for what happened," she said, "but the coroner has missed the opportunity to highlight what went wrong and why.
"That doesn't give me any confidence that this won't happen again, which is what we have been fighting all these years to prevent.""No evidence of criminal involvement," say police
THE police were forced to re-examine Anthony Billy's death last year after his family complained about the way the original investigation was handled.
After a cursory investigation, officers concluded he had taken his own life and, according to Simmone Simpson, Mr Billy's sister, told the family: "This is what people with mental health issues do. They become unwell and they end it."
It later emerged that police had not interviewed members of staff at Russell Hill Lodge, failed to submit the fuel cannister and lighter for forensic examination and had lost CCTV footage of Mr Billy at the petrol station during the download process.
The family contacted the Independent Police Complaints Commission and, last summer, the investigation was reopened. The detective leading the new effort told the Advertiser there had been "gaps" in the initial inquiry.
Ms Simpson believes police "prejudice" meant the original probe was closed without the drug-debt angle being properly investigated. Their fears were increased when a school friend said Mr Billy had told him in the days before his death that "bad people were out to get him".
After the conclusion of the inquest, a Metropolitan Police spokesman said the second investigation had found "no evidence of criminal activity or third party involvement".
Mr Billy's family have been invited to meet with South London and Maudsley, which runs Russell Hill Lodge, to discuss lessons the NHS trust can learn from his death.
