Inquest into the Death of Leslie Charles LINTON
Inquest into the Death of Leslie Charles LINTON
Delivered on : 5 December 2025
Delivered at : Perth
Finding of : Acting State Coroner Linton
Recommendations : N/A
Orders/Rules : N/A
Suppression Order : N/A
Summary : Leslie Linton died on 30 December 2023 at Royal Perth Hospital from a heart-related condition.
He was an involuntary psychiatric patient, pursuant to the Mental Health Act 2014 (WA) at the time of his death, so he came within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA) and a coronial inquest into his death was mandatory.
Leslie Linton was born in Myanmar (Burma) on 22 March 1959. He came to Australia with extended family at the age of 10 and settled in Perth. He attended school until Year 9. He left school at the age of 16 years and began working with the hope of becoming a motor mechanic. He then joined the Army at 19 years of age.
Mr Linton married and had two children. In 2010, following the breakdown of his marriage Mr Linton appeared to experience mental health issues and he made an impulsive decision to take his mother’s car and drive to Queensland. He lived in Queensland for approximately the next 12 years and had limited contact with his family during this time, despite their attempts to stay connected.
While living in Queensland Mr Linton experienced homelessness, along with physical and mental health issues. Between 26 April to 3 May 2023 Mr Linton was admitted to the Cairns Hospital after suffering a heart attack. Tests revealed that he had severe triple-vessel coronary artery disease. Evidence indicates Mr Linton was not compliant with his medication regime after hospital discharge.
Mr Linton’s family in Perth became aware of his hospital admission and Mr Linton’s daughter began making enquiries to try to locate him. She noted his address was listed as The Salvation Army Cairns. She called them and left a message for him. In August of 2023 Mr Linton’s daughter re-established contact with her father by phone and they began to speak on the phone every Sunday. In October 2023 she managed to convince her father to return to Perth.
Following his return to Perth on 9 December 2023, Mr Linton lived with his daughter and her family for approximately one week, during which time he became increasingly agitated, paranoid, and delusional.
Mr Linton saw a general practitioner on 12 December 2023. It was found that his blood pressure was high, and that he had raised cholesterol and poorly controlled diabetes, all of which contributed to his cardiovascular risk. He was re-prescribed his medications but seemed reluctant to take them as he believed natural alternatives, such as turmeric, would suffice. The doctor and Ms Linton also had concerns about his mental health. He was easily agitated when challenged about his delusions.
Mr Linton’s daughter contacted staff at the City East Mental Health Service for help on 14 December 2023 in relation to her father’s agitation. It was arranged that staff would attend for a home visit with a police escort the next day. However, prior to this occurring Ms Linton arranged for her father to attend Royal Perth Hospital on the morning of 15 December 2023. He requested a medical review of his infected foot but Ms Linton also requested a psychiatric review. Mr Linton was admitted to the Acute Medical Unit for treatment of his physical health issues, with a note that he would also require psychiatric assessment.
Mr Linton received cardiology input, and it was recommended that he undergo cardiac surgery. However, Mr Linton would not provide his consent.
On 17 December 2023 Mr Linton was psychiatrically assessed while still on the medical ward. The impression was of untreated schizophrenia or possible psychotic depression, as well as possible organic causes including uncontrolled diabetes and vascular disease. Once he was physically stable, it was decided he would move to the Psychiatric unit where the reasons for his cognitive issues could be further explored. He was detained under the Mental Health Act 2014 for management and care.
Mr Linton was reviewed by a consultant psychiatrist, who thought Mr Linton’s mental health issues were most likely related to his vascular issues. Steps were commenced to meet with his family to assist them to seek a guardianship order, with the hope this would allow for Mr Linton to have the life-saving cardiac surgery in due course. Before this could occur, Mr Linton’s health rapidly deteriorated.
At 11.00am on 30 December 2023 it was recorded that Mr Linton had low blood pressure. Aside from the low blood pressure reading it was noted that he was asymptomatic with all other vital signs within normal limits. After being placed on 30 minute observations at 3.00pm, Mr Linton was found unconscious on the floor. A code blue was initiated but he could not be revived.
Following a post mortem examination, a forensic pathologist formed the opinion Mr Linton died from an acute myocardial infarction (heart attack) in association with coronary artery atherosclerosis.
The Acting State Coroner found Mr Linton died as a result of natural causes.
Catch Words : Mandatory Inquest: Involuntary patient: Mental Health Act : Natural Causes
Last updated: 18 December 2025