Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0158, written 19 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2026 |
|---|---|
| Reference | 2026-0158 |
| Deceased | John Beagley |
| Coroner | Roland Wooderson |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
H M Area Coroner for Gloucestershire Mr Roland Wooderson 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. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk 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. 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. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk 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 DATE 19 March 2026 Roland Wooderson HIS MAJESTY’S AREA CORONER FOR GLOUCESTERSHIRE Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 18 May 2026 HM Area Coroner Roland Wooderson Gloucester Coroner’s Court, Corinium Avenue, Gloucester GL4 3DG Dear Mr Wooderson, Thank you for the Regulation 28 report of 19/03/26 sent to the Secretary of State and the Department of Health and Social Care about the death of Mr John David Beagley. I am replying as the Minister with responsibility for Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Beagley’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over a national shortage of oral and maxillofacial (OMF) surgeons and consultants which could impact on the care of patients. The report also raised concerns that a perceived long training period for these specialists, including long elements not funded by the NHS but by the student themselves, is making this a more unattractive specialty. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand your concern about the number of OMF surgeons and how important it is to retain this workforce to appropriately support patients. The Government also recognises the unique training pathway that is required to become an OMF surgeon, with applicants needing to have both a medical and dental degree. As of January 2026, there are over 1,300 full-time equivalent (FTE) doctors working in the specialty of OMF Surgery in NHS trusts and other core organisations in England. This is over 30 (2.4%) more than in 2025, over 50 (4.2%) more than in 2021, and almost 400 (41.8%) more than in 2010.This includes over 400 FTE consultants. This is over 5 (1.4%) more than in 2025, over 30 (8.7%) more than in 2021, and almost 160 (61.8%) more than in 20101. In 2025, OMF Surgery ST1 (entry level specialist training) filled 100% of posts (16/16), indicating complete recruitment at entry level and a stable inflow into the training pipeline. 1 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/january-2026 This has increased from 75% in 2024 (12/16) and matched its 100% fill rate in 2020 (9/9)2. Competition ratios further support an increase in entry level demand. In 2025, OMFS ST1 had a competition ratio of 3.50 (77 applications for 22 posts). This has increased from 1.89 in 2024 (34 applications for 18 posts) and as of 2025, there are 147 trainees in the OMF Surgery training programme. This is 1 (0.7%) more than in 2024 and 9 (6.5%) more than in 20203. Up until 2026, there has been another application point for the specialty at ST3, which is a part of higher specialty training and requires applicants to have completed core training and relevant exams. Due to reducing fill levels at ST3, all recruitment for OMF Surgeons will be at ST1 from 2027 onwards. At ST1 level (run-through training), applicants are more likely to have both a medical and a dental degree. However, by the time resident doctors are eligible to apply at ST3 level, they are either unlikely to have both degrees (and therefore not eligible) or for various reasons they wish to work in particular region and posts may not be available where they want to work. Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient and appropriate staff to provide safe care. I would expect NHS Trusts to review their staffing levels, and access to specialists where needed, to ensure that they are appropriate to treat patients who come forward seeking care. Trusts already have a duty through the Health and Social Care Act 20084 to regularly review the number of staff and range of skills needed to safely meet the needs of people using their services As your report raised, and I mentioned earlier, OMF surgeons have a lengthy training process whereby they train as both doctors and dentists before beginning the specialist training to become a fully fledged consultant in their field. There are some universities that offer a shortened 3-year postgraduate degree for qualified doctors who want to go into the OMF field and I believe the appropriate Specialty Advisory Committee within the Faculty of Dental Surgery are working with universities to expand these courses. There is a high competition ratio for places on these courses, further implying desire among medical graduates to work in OMF specialties. I fully appreciate the concerns about costs for training. The Department for Education is bringing forward a Lifelong Learning Entitlement (LLE) system which will mean an improved funding offer for individuals studying medicine or dentistry as a second degree. From January 2027, all courses funded by the current Student Finance England (SFE) system will be funded by the new LLE system. 2 https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/fill-rates 3 https://gde.gmc-uk.org/postgraduate-training/postgraduate-trainees/postgraduate-trainees-summary-data 4 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 18 Currently, students undertaking medicine or dentistry as a second degree are required to either partially or fully self-fund their tuition fees in study years that are not covered by the NHS Bursary. Under LLE, eligible students choosing medicine or dentistry as a second degree will be able to access maintenance support and full tuition fee loans during these years. Those who qualify will still be able to receive the NHS Bursary from year two of a graduate-entry programme or from year five of a standard 5-6 year long course. The NHS Bursary comprises non-repayable support for tuition fees and where eligible, further grants and allowances. The Government keeps the funding arrangements for all healthcare students under close review. At all times we must balance the level of support students receive with the need to deliver as much value as possible for taxpayers’ money. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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