A coroner has raised concerns and demanded 'urgent action' after a man was found dead at sea in Dorset having been released from police custody.

Ivan Rumenov Ignatov, 24, was found in the water off Church Ope Cove, Portland on July 31, 2020 - nearly two weeks after he was seen walking into the sea.

An inquest into his death was held at Bournemouth Town Hall in May which heard that the Bulgarian national had been struggling with his mental health.

Senior coroner Rachael Griffin ruled that Mr Ignatov died as a consequence of drowning in open water, adding that his intentions for entering the sea 'remain unclear'.

In a prevention of future deaths report published on Monday, June 12, Ms Griffin said evidence revealed during the inquest gave 'rise to concern' and that 'there is a risk that future deaths will occur unless action is taken'.

On July 19, 2020, Mr Ignatov had been released from custody at Weymouth Police Station after reportedly attacking his father in Sturminster Newton the day before.

After being released, it was alleged he attempted to steal a car on Portland until he was 'punched' by one of its occupants and fled with a bloody nose.

Mr Ignatov was then seen entering the sea at Church Ope Cove at about 10.20pm that night.

Ms Griffin's report states that he spoke 'limited English' and had never been arrested before being taken into custody.

Mr Ignatov, who came from Bulgaria, was released by officers without an address to reside at - although an offer had been made to take him to his home address in Sturminster Newton to collect his belongings before transporting him to a hotel. 

Whilst waiting for officers to arrive to take him, Mr Ignatov left the station on his own and made his way to Portland.

Ms Griffin said that during his time in custody, the 24-year-old required a face-to-face assessment by the mental health practitioner, which 'did not happen'.

He had also 'placed clothing around his neck' while in custody but this was not referred to mental health services.

"At this time his risk of harm was assessed as low as his clothing had been replaced by rip stop clothing," Ms Griffin's report said.

The Dorset coroner also raised concerns that it was not recorded 'anywhere on the custody record or paperwork' that this was Mr Ignatov's first time being arrested.

She said that there is 'no formal guidance' given to sergeants or officers as to what to do when a detainee has no place to reside upon release from custody.

Ms Griffin added: "Upon his release from police custody, Ivan was given leaflets detailing the mental health services he could access.

"These were given in English. They were not translated or explained to him."

Ms Griffin was also critical of the communication between emergency services and search and rescue teams involved in the events on July 19.

Mr Ignatov was seen 'acting erratically and stumbling along the rocky terrain' on Portland's cliffs as he was followed by the national police helicopter and officers on-foot. 

"There appears to be from the evidence a lack of understanding between emergency services and search and rescue teams about the work each other undertakes, the language and terms they use, and the tasks they undertake," Ms Griffin states.

The coroner said there was an incorrect assumption by staff in the police command centre that a lifeboat had been launched when in fact it had not.

In her report, Ms Griffin concluded that 'urgent action should be taken to prevent future deaths' following the passing of Mr Ignatov.

Last month's inquest heard that he moved to the UK with his parents in 2017 and worked as a machine operator.

His mother, Katrina, said he was a 'well respected' young man who had a large circle of friends.

Ms Griffin's report has been sent to several agencies involved in the case of Mr Ignatov, and the coroner has requested they respond with details of actions taken or proposed by August 3, 2023.