John Beagley: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
Skip to related content
Date of report: 19/03/2026
Ref: 2026-0158
Deceased name: John Beagley
Coroner name: Roland Wooderson
Coroner Area: Gloucestershire
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Secretary for State Department of Health & Social Care | |
| 1 | CORONER I am Roland Wooderson Area Coroner for the coroner area of Gloucestershire |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 3 July 2025 I commenced an investigation into the death of JOHN DAVID BEAGLEY aged 72. The cause of death was 1a squamous cell carcinoma 2. Myelofibrosis. The investigation concluded at the end of the inquest on 19 March 2026. The conclusion of the inquest was Mr Beagley died of squamous cell carcinoma following treatment for carcinoma of the scalp. He underwent surgical excisions in November and December 2023, after which pathology demonstrated that cancerous tissue remained. Further treatment, including radiotherapy, was agreed upon. From February 2024, plans were made for radiotherapy once his surgical wound had healed. However, the wound did not heal and concerns were raised by clinicians about the lack of improvement. A radiotherapy referral was not submitted, and opportunities to referral Mr Beagley for radiotherapy were missed. |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Beagley died of squamous cell carcinoma as detailed above. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. During the course of the inquest, the Court heard evidence that: 1. There was a national shortage of maxillofacial surgeons/consultants. 2. The said shortage could impact upon the care of patients. 3. It was perceived that the long medical training for such surgeons (including dentistry training) was unattractive for prospective surgeons due to the fact that a large element of the training was not funded by the NHS and would have to be funded from the clinician’s own finances. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 May 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the family of Mr Beagley and Gloucestershire Health and Care NHS Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 19 March 2026 Roland Wooderson HIS MAJESTY’S AREA CORONER FOR GLOUCESTERSHIRE |