JOHN DAVID BEAGLEY · Prevention of Future Deaths report

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.

By July 2024, imaging showed that the cancer had progressed. Radiotherapy was eventually administered between September and October 2024, but his condition deteriorated thereafter and he died in December.

Expert reviews obtained by the Hospital Trust concluded that the cancer demonstrated aggressive behaviour, influenced by Mr Beagley’s underlying immunosuppression. The delay in referral and escalation reduced the opportunity for earlier disease control.

Mr Beagley died of squamous cell carcinoma as detailed above.

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.