Ontario’s Ministry of the Solicitor General has confirmed that an inquest into the death of Brent Moore, a 40-year-old man who died in 2020 after being transferred from the Sarnia Jail, will begin later this month.
The announcement was made Monday by Dr. Elizabeth Urbantke, Regional Supervising Coroner for the West Region, London Office. The inquest, which is mandatory under the province’s Coroners Act, will start at 9:30 a.m. on Monday, September 22, 2025. Dr. Geoffrey Bond has been appointed presiding officer, with Indira Stewart serving as inquest counsel.
“Dr. Elizabeth Urbantke, Regional Supervising Coroner for West Region, London Office, announced today that a date has been scheduled for the inquest into the death of Brent Moore,” the Ministry said in its release. “The inquest will begin at 9.30 a.m. on Monday, September 22, 2025. Dr. Geoffrey Bond will be the presiding officer and Indira Stewart will be the inquest counsel.”
Circumstances of Moore’s death
Moore died in hospital on August 30, 2020, after being transferred from the Sarnia Jail. His death triggered provisions in the Coroners Act, which require an inquest into deaths that occur while an individual is in custody or under institutional care. The inquest is designed not to assign blame but to examine the facts and explore ways to prevent similar tragedies.
“Mr. Moore, 40 years old, died in hospital on August 30, 2020, after being transferred from the Sarnia Jail. An inquest into his death is mandatory under the Coroners Act,” the announcement stated.
Scope of the inquest
The Ministry confirmed that the inquest will focus on the circumstances surrounding Moore’s death and could result in jury recommendations directed at improving safety and oversight in Ontario’s correctional and health systems.
“The inquest will examine the circumstances surrounding Mr. Moore’s death. The jury may make recommendations aimed at preventing further deaths,” the release said.
Inquests in Ontario are intended to serve as public inquiries. While they do not establish legal responsibility, they can play a critical role in exposing gaps in procedures, highlighting systemic concerns, and shaping policy reforms. Past inquests have led to changes in correctional operations, mental health care, and emergency medical response.
Structure and timeline
According to the Ministry, Moore’s inquest is expected to run for five days, during which time the jury will hear testimony from about eight witnesses. These witnesses could include medical professionals, correctional staff, and experts who can provide context about institutional protocols and standards of care.
“The inquest is expected to last five days and hear from approximately eight witnesses,” the statement said.
Inquests are directed by a presiding coroner and heard by a jury of five members. After reviewing the evidence, the jury issues a verdict on the circumstances of the death and may put forward recommendations designed to reduce risks of recurrence. While those recommendations are not legally binding, they often shape government and institutional practices.
Public access
In line with a commitment to transparency, the Ministry said the proceedings will be conducted virtually. Members of the public and media can observe the inquest in real time through a live video conference link.
“The inquest will be conducted by video conference. Members of the public who wish to view the proceedings can do so live at the link provided below,” the release said.
The link for access is hosted through First Class Facilitation, a platform that manages online proceedings for the Office of the Chief Coroner: View Proceedings.
For those seeking additional context, the Ministry pointed to resources available online. “For more information about inquests, see: https://www.ontario.ca/page/coroners-inquests,” the announcement added.
Broader context
The inquest into Moore’s death comes amid ongoing public scrutiny of Ontario’s correctional system, where concerns about overcrowding, access to health care, and systemic risks have been raised repeatedly. While the specifics of Moore’s case will be the focus of the proceedings, the jury’s recommendations could influence broader reforms and policies within the province.
For families, communities, and policymakers, the inquest offers an opportunity to seek greater clarity on the events leading to Moore’s death and to consider safeguards that might prevent future losses.
