John Beagley

I am Roland Wooderson Area Coroner for the coroner area of Gloucestershire

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.

Mr Beagley died of squamous cell carcinoma as detailed above.

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.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.