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Sudden, unexpected cardiac or unexplained death in England: a national survey

T.J. Bowker, D.A. Wood, M.J. Davies, M.N. Sheppard, N.R.B. Cary, J.D.K. Burton, D.R. Chambers, S. Dawling, H.L. Hobson, S.D.M. Pyke, R.A. Riemersma, S.G. Thompson
DOI: http://dx.doi.org/10.1093/qjmed/hcg038 269-279 First published online: 1 April 2003


Background: Post‐mortem examinations of adults who were apparently healthy but died suddenly and unexpectedly sometimes reveal no morphological abnormalities to explain their deaths. The frequency of such unexplained deaths in relation to other causes of sudden cardiac death is not known.

Aim: To estimate the frequency of sudden unexpected cardiac or unexplained death in England.

Design: Prospective survey using a stratified random sample of 83 of the 132 H.M. Coroner's jurisdictions in England.

Methods: Consecutive White Caucasians, aged 16–64 years, with no medical history of cardiac disease, seen alive within 12 h of death, on whom autopsy found either a cardiac or no identifiable cause of death, were included. The coroner's officer sent a copy of the post‐mortem report and a completed case registration form to the investigators, with tissue samples.

Results: Sixty‐seven (81%) coroners participated, each maintaining prospective surveillance for 4 months. Of 692 ascertained cases, case registration forms were received for 650 (94%), post‐mortem reports for 682 (99%), blood samples for 569 (82%), myocardial slices for 517 (75%) and whole hearts for 47 (7%). In cases with myocardial tissue, death was ascribed to ischaemic heart disease in 465 (82.4%). In 43.1% the ischaemia was acute, in 19.1% there was myocardial scarring but no acute ischaemia, and 20.2% had coronary atheroma only. Death was due to left ventricular hypertrophy in 32 (5.7%), to other cardiac causes in 30 (5.3%) and in 23 (4.1%) there was no clear cause. Those with cardiac causes were 81% male, median ages 55.9 (male) and 56.6 (female) years. The 23 unexplained deaths were 57% female, median ages 40.5 (male) and 54.9 (female) years. The estimated annual frequency of sudden unexpected death due to cardiac or unidentified causes, in English adults of employment age, was 11/100 000 (3481 annual deaths).

Discussion: In 4.1% of sudden unexpected deaths under 65 years, no cause was found. Until it becomes accepted practice to identify these cases by a name, such as Sudden Adult Death Syndrome (SADS), it will not be possible to study their aetiology systematically.


There are occasions when post‐mortem examination of an apparently previously healthy adult who has died suddenly and unexpectedly reveals no morphological abnormalities to explain their death. Whether such occasions are extreme rarities, or represent the tip of a larger iceberg, remains uncertain. In England, when the deceased was not under medical care prior to death, or the deceased's medical practitioner does not know the cause of death, or when death could be due to unnatural causes, the death must be reported to Her Majesty's Coroner, who investigates the cause. Coroner's cases are included in the mortality statistics published by certified cause by the Office of Population Censuses and Surveys,1 but for the deaths attributed to ischaemic heart disease, no distinction is drawn between those with and without an ante‐mortem history of the disease. Thus neither the UK national frequency of sudden unexpected cardiac death, nor of those sudden unexpected adult deaths in which the cause is difficult or impossible to identify, are known. Whether the latter should be classified as the adult equivalent of the sudden infant death syndrome has been raised.2

The aim of the present survey was to measure prospectively throughout England the occurrence and circumstances of consecutive sudden unexpected adult deaths due to cardiac or to unidentified causes, and to collect prospectively post‐mortem reports and tissue samples from such cases, ascertained by a stratified random sample of Coroners' jurisdictions. This paper describes the survey's principal results.


The methodology developed in a pilot study has been published.3 A summary, which includes modifications to the pilot methodology, follows.

Case definition

Sudden unexpected adult death cases were defined as: (i) white Caucasians; (ii) between the ages of 16 and 64 years (inclusive); (iii) with no medical history of heart disease; (iv) who were last seen alive within 12 h of being found dead, and (v) for whom a death certificate could not be issued without a coroner's post‐mortem, at which either a cardiac or no identifiable cause of death was found. A history of hypertension alone (i.e. in the absence of any other signs or symptoms of heart disease) did not exclude subjects from the survey.

Sampling frame and sample size

The sampling frame was a list of the 132 coroner's districts of jurisdiction in England, ranked primarily geographically and secondarily by 1992 annual caseload (which ranged from 70 to 4956 cases). The list was divided into four groups of 33 jurisdictions, each group being comparably distributed both geographically and in terms of coroner's workload. The four groups were randomly ordered; the first group of jurisdictions started surveillance on 25 October 1993 and the third group on 27 March 1995. The fourth group of coroners was not required. Each jurisdiction maintained prospective surveillance for cases (as defined above) for a four‐month period. Altogether, 83 coroners were invited to participate in the survey and 67 (81%) did so. The total period of surveillance across England was about two years.

Surveillance and case ascertainment

Each coroner and/or their officer completed a check‐list (the Death Record Form) on each deceased referred for post‐mortem examination, to maintain surveillance for the deceased's race, age, past medical history and when last seen alive (the first four of the above inclusion criteria), so as to advise the coroner's pathologist whether the deceased was eligible for the survey. If the coroner's pathologist then found either a cardiac or no identifiable cause of death (the fifth inclusion criterion), tissue specimens were collected from the case. For the deceased who met all five inclusion criteria, the coroner's officer sent a copy of the post‐mortem report and a completed Case Registration Form to the investigators. Fifty‐seven jurisdictions used Death Record Forms as their means of prospective self‐audit of case ascertainment.3 The remainder set up their own case surveillance mechanisms.

Data and tissue collection

Information requested on the Case Registration Form included the deceased's name and date of birth, the time and circumstances of death, and their general practitioner's name and address. Coroner's officers attached a copy of their own report of the circumstances of death to the Case Registration Form. The following tissue specimens were requested.


A transverse myocardial slice (1 cm thickness) through both ventricles at mid‐septal level (or equivalent in piecemeal form) was fixed in a formalin‐based fixative for 48 h. Excess formalin was poured off, and the slice was placed in a container.


Ten millilitres of blood were placed in a plain blood bottle and 2 ml in a fluoride bottle. Each specimen container was labelled and despatched to the investigators.

Case registration forms, specimen containers, stamped addressed envelopes and packaging had been provided in advance by the investigators.

In those cases in whom macroscopic inspection of the transverse myocardial slice revealed no evidence of infarction or ischaemia and in whom neither significant coronary disease nor any other identifiable cause of death was found at post mortem, the whole heart (rather than just the myocardial slice) was sent to the investigators for examination, and the blood underwent central toxicological screening by the investigators. (Prior toxicological screening by the coroner had excluded cases of suspected substance abuse.)

Histology reporting and coding of causes of death

Whole hearts and myocardial slices were all examined macroscopically and histologically in a standard manner, by the study's own consultant cardiac histopathologists. On each case on whom tissue was available, the coroner's post‐mortem report, the coroner's officer's report and the investigators' own histological and toxicological findings were reviewed by a panel (MJD, MNS and TJB), who classified the cause of death into one of 27 possible categories (Appendix A). Cases for whom no tissue was available were classified in a similar manner, but without the benefit of study's own independent histological reports.

Death registration and investigator's report to coroner

The investigators reported their pathological findings directly to the coroner. Coroners did not have to delay registration of deaths; they were able to indicate to the Registrar that the results of histological examination were to follow.

Denominator population

The denominator population in which cases arose was the sum of the catchment populations of the participating jurisdictions. These were estimated by using the Office of Population Censuses and Surveys 1994 age‐specific mid‐year population estimate for English counties and metropolitan areas and, for those counties with more than one coroner, weighting each county's age‐specific population between jurisdictions by coroners' annual caseload.


Coroner participation and case registration

Sixty‐seven jurisdictions (81% of those invited) participated in the survey. A total of 10 724 Death Record Forms were returned to the investigators from the 57 jurisdictions that used them. From all 67 jurisdictions, 1029 sudden cardiac or unexplained deaths were registered, 1003 of which met the first four inclusion criteria of the case definition. In 278 of these deaths a definite non‐cardiac cause of death was found at post‐mortem examination. On a further 33 deaths, there was insufficient information available for diagnostic classification. This left a total of 692 true cases.

Completeness of data and tissue collection

Of the 692 true cases, case registration forms were received for 650 (94%), post‐mortem reports for 682 (99%), blood samples for 569 (82%), myocardial slices for 517 (75%), whole hearts for 47 (7%), and no tissue for 128 (18%). For 528 (76%), a complete dataset (post‐mortem report, case registration form and tissue) was received (Table 1).

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Table 1

Case registration by data received

Whole heartsMyocardial slicesNo tissueTotal
Cases, as defined47 (7%)517 (75%)128 (18%)692 (100%)
Case registration forms44495111650 (94%)
Post‐mortem reports46511125682 (99%)
Blood samples4651310569 (82%)
Myocardial tissue475170564 (82%)
Complete datasets424860528 (76%)
Panel review47517128692 (100%)

Classification of causes of death

The causes of death to which cases were categorized by the panel are summarized in Table 2. Of the 564 (81.5%) cases on whom myocardial tissue was available, 465 (82.4%) were classified as having died due to some manifestation of coronary disease, 32 (5.7%) to left ventricular hypertrophy, 30 (5.3%) to other cardiac causes, and in 23 (4.1%) there was no clear cause. Three other cases (0.5%) also had no clear cause; however, one of these had Down's syndrome, and in the other two prescribed drugs were detected in the blood at non‐toxic levels. Eleven other subjects (2%) had an ante‐mortem history of epilepsy (4 cases) or of previous alcohol abuse (7 cases). Their deaths had been attributed to cardiac disease (1 epilepsy, 3 alcohol abuse) or to no clear cause (3 epilepsy, 4 alcohol abuse), and are tabulated separately. Details of the other 30 cases with other cardiac causes of death are given in Table 2 (also given in Table 2 is the classification of cases on whom myocardial tissue was not available).

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Table 2

Causes of death allocated by panel review

Cases with no myocardial tissueCases with myocardial tissue
Ischaemic heart disease
Acute ischaemia (acute infarction and/or coronary thrombosis)47 (36.7%)243 (43.1%)
Myocardial scarring (without acute ischaemia/infarction)25 (19.5%)108 (19.1%)
Coronary atheroma only (without acute ischaemia or scarring)23 (18.0%)114 (20.2%)
Subtotal95 (74.2%)465 (82.4%)
Left ventricular hypertrophy20 (15.6%)32 (5.7%)
Aortic valve stenosis5 (3.9%)7 (1.2%)
Idiopathic myocardial fibrosis syndrome05 (0.9%)
Other cardiac
Hypertrophic cardiomyopathy03 (0.5%)
Dilated cardiomyopathy01 (0.2%)
Mitochondrial cardiomyopathy01 (0.2%)
Right ventricular dysplasia01 (0.2%)
Myocarditis1 (0.8%)4 (0.7%)
Anomalous coronary artery01 (0.2%)
Floppy mitral valve03 (0.5%)
Sarcoidosis02 (0.4%)
Endocarditis3 (2.3%)0 (0.0%)
Lipomatous hypertrophy of interatrial septum01 (0.2%)
Metastatic tumour01 (0.2%)
Subtotal4 (3.1%)18 (3.2%)
No clear cause
With no co‐morbidity023 (4.1%)
With Down's syndrome01 (0.2%)
With prescribed drugs detected02 (0.4%)
History of alcohol abuse
With normal heart4 (3.1%)4 (0.7%)
With heart disease03 (0.5%)
History of epilepsy
With normal heart03 (0.5%)
With heart disease01 (0.2%)
Total128 (100%)564 (100%)

Age and gender distributions

The 527 cases with myocardial tissue for whom a cardiac cause of death was found were predominantly male (81%), with the genders having similar age distributions: male and female median (range) ages were 55.9 (19.5–64.9) and 56.6 (24.4–64.9) years, respectively. By contrast, in the 23 unexplained deaths, not only were females more frequent (57%), but also age at death differed between genders: male and female medians (range) being 40.5 (16.0–64.9) and 54.9 (25–62.3) years, respectively.

Occurrence rates

Based on the estimated age‐specific catchment populations of the participating coroner's jurisdictions (total 15 348 301 people), the frequency of sudden unexpected death due to cardiac causes was estimated to be 10.5 per 100 000 per annum and to unexplained causes 0.5 per 100 000 per annum, in English adults of employment age. If the 128 cases for whom no tissue was received are included in the numerator, the estimate due to cardiac causes rises from 10.5 to 13 per 100 000 p.a.


This national survey has demonstrated that, despite an expert histopathological examination, there remains a proportion of sudden unexpected adult deaths in whom no definite cause of death can be found. The proportion unexplained in this national survey (4.1%) is consistent with that (4.7%) measured in a Wandsworth survey reported in 1988,4 although there are some differences in case definition between the two studies.

The frequencies of sudden unexplained death in Thailand5,,6 and in Singapore7 have been surveyed, and a retrospective study of the occurrence and causes of sudden unexpected non‐traumatic death in a Minnesota county8 has also been reported. In addition, the rate of occurrence of sudden cardiac death, and its triggers, have been studied in subjects with previously diagnosed cardiac disease in North America9–,12 and Europe,13–,16 and in subjects both with and without previously diagnosed cardiac disease in the UK.4,17–,20

Our survey has provided an estimate of the national rate of sudden unexpected cardiac adult death (10.5 per 100 000 per annum). The rate of sudden unexpected adult deaths measured by this survey to be due to ischaemic heart disease (9.1 per 100 000 per annum) is 20% of the entire national ischaemic heart disease death rate, in the same age group. These occurrence rates would be equivalent to a total of 3338 cardiac, and of 143 unexplained, sudden and unexpected deaths, in adults of employment age throughout England each year.

These cardiac deaths have implications for the early detection and management of cardiac disease. The unexplained deaths raise two issues. The first, and immediate, issue is how best to counsel the relatives of such victims and investigate the surviving family members for cardiac disease. The second, and longer term, issue is how to develop a strategy for investigating the aetiology of such tragedies, thereby hopefully leading to their prevention. English coroners, who must be qualified solicitors or barristers (and may also be medically qualified), were instituted 800 years ago, and in legal antiquity are second in the Realm only to the Lord Chancellor. The verdict of a Coroner's Court has not been challenged, even by the House of Lords. It is most unlikely that any sudden unexpected cardiac or unexplained death occurring in England during the period of this survey would not have been reported to the Coroner. Nevertheless, our occurrence rate estimates (both of cardiac and of unexplained death) are liable to be conservative. While all cases are likely to have been referred to coroners, some may have escaped the surveillance mechanism within some jurisdictions.

In the pilot survey performed to develop the present methodology, an independent retrospective audit of completeness of case ascertainment detected a median true ascertainment rate of 75%.3 Accordingly, the Death Record Form was introduced into the main survey's methodology, to provide a concurrent self‐audit mechanism to minimize underascertainment due to incomplete surveillance. The ten jurisdictions which did not use this self‐audit mechanism ascertained a total of 56 cases with myocardial tissue (only 10% of the total of 564). While the 10 jurisdictions are 15% of the total of 67 participating, the aggregate of their estimated catchment populations was 2 899 205 (19% of the total). Thus it is not unreasonable to assume incomplete surveillance within these 10 jurisdictions. If occurrence rates in 19% of the population have been underestimated by 25%, then our overall estimates should be increased by 6%. Even in the 57 jurisdictions using the self‐audit mechanism, there is no guarantee that ascertainment was 100%. However, it is safe to conclude that our figures are not over‐estimates of sudden unexpected adult cardiac and unexplained death rates.

The proportion of cases in whom there was no clear cause of death is likely to be a conservative estimate, not only because of incomplete surveillance in some jurisdictions, but also because allocation to this category has been strict. All such cases were apparently healthy, with no reported co‐morbidity prior to their sudden unexpected death, and had a negative toxicological screen for prescribed or illicit drugs. If a sudden adult death syndrome exists, then from time to time it is liable to occur in individuals who have a past history of alcohol abuse or of diseases such as epilepsy or Down's syndrome, or who may be taking prescribed medication. Nevertheless, the ten individuals who fell into one of these groups (epilepsy, alcohol, prescribed drugs detectable on toxicological screen, Down's syndrome), and who had no clear cause of death, have been classified separately from the 23 unexplained cases in whom there was no co‐morbidity. While the proportion of cases due to unidentified causes is certainly not less than 4.1%, this proportion might be greater if some of the unexplained cases with co‐morbidity were in fact truly unexplained. Whatever the truth of the matter, a similar apparent excess of sudden unexpected adult death in epileptics and in alcoholics was detected in the Wandsworth survey.4 However, it is not possible to estimate their rates, as both surveys made no attempt to make complete ascertainment of such cases with co‐morbidity.

In cases in whom coronary atheroma was the only finding, the question arises as to whether it was incidental.21,,22 While coronary atheroma is ubiquitous in Western populations from an early age, a distinction needs to be drawn between its presence and ischaemic heart disease as the cause of death; the latter requires support from other evidence: high‐grade stenosis, thrombosis or old or recent infarction.13,,23 In the present survey, coronary thrombosis may have gone undetected in a proportion of the cases in whom coronary atheroma only was found.

In England, the frequency of coroner's post mortem cases with no morphological abnormality (or with only co‐incidental coronary atheroma) is unknown, because there has been no agreed nomenclature for categorizing and recording them.2 Some coroners have accepted a diagnosis of ‘natural death—cause unascertained’; others have not. A pathologist may be tempted to ascribe death erroneously to ischaemic heart disease or to minor conduction system abnormalities.24 A category of ‘sudden adult death syndrome’ is proposed for those victims who were previously well and whose heart is morphologically normal at necropsy.2

In the present survey, unexplained cases had different age and gender distributions to those due to cardiac causes. This may in part simply indicate that it is easier in older subjects to find some pathological cardiac abnormality to which to ascribe death (but whether such abnormality was causal or coincidental remains open to discussion). Nevertheless, the differing age and sex distributions are consistent with the idea that the unexplained cases are a separate entity to those with recognized cardiac causes.

The unexplained cases found in this survey are in fact likely to have causes, which at present cannot be identified. However, until it is accepted practice to identify such cases and label them as such (rather than attribute them to a currently recognized cardiac cause of death without good evidence), it will not be possible to study them systematically and thus identify their cause(s). These sudden unexplained natural deaths should be registered as sudden adult death syndrome.

Appendix A: Categories of causes of death

Coronary disease

Acute ischaemia or infarction, with prior myocardial scarring

Acute ischaemia or infarction, without prior myocardial scarring

Acute ischaemic haemopericardium, with prior myocardial scarring

Acute ischaemic haemopericardium, without prior myocardial scarring

Prior myocardial scarring, without acute ischaemia or infarction

Atheromatous coronary artery disease only, without acute ischaemia or infarction, prior myocardial scarring, or LVH

Left ventricular hypertrophy (LVH)

LVH with no history of hypertension or ischaemic heart disease

LVH with history of hypertension, but no ischaemic heart disease

LVH with coronary atheroma, but without acute ichaemia or prior myocardial scarring

LVH with aortic stenosis, and no ischaemic heart disease

LVH with both aortic stenosis and hypertension, but no ischaemic heart disease

Other cardiac

Idiopathic myocardial fibrosis syndrome

Hypertrophic cardiomyopathy

Dilated cardiomyopathy

Right ventricular dysplasia


Mitochondrial myopathy


Right atrial pathology

Anomalous coronary artery

Floppy mitral valve

Aortic stenosis with coronary artery disease, but without acute ischaemia or prior myocardial scarring

Aortic stenosis without coronary artery disease or LVH Endocarditis

Primary tumour

Metastatic tumour

No cause found

Associated conditions



Appendix B: Participating coroners and their jurisdictions


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Appendix C: Participating coroners' pathologists

Dr R.A. Jones, Dr M.A. Nurbhai & Dr C. Ritchie, Middlesborough General Hospital

Dr J. Hoffman & Dr K. Karczenski, North Tees General Hospital, Stockton

Dr J.H. McCarthy & Dr K.P. Pollard, South Tyneside District Hospital, South Sheilds

Dr J.P. Sunter, Dr M.J. Egan & Dr P.A. Cross, Queen Elizabeth Hospital, Gateshead

Dr M.R.B. Wetherall, Dr H.R. Cochrane, Dr J.H. McElroy & Dr K.V. Prasad, Sunderland District General Hospital

Dr A.W. Popple, Dr F.I. Young & Dr E.D. Long, Cumberland Infirmary, Carlisle

Dr D. Smith & Dr R.G. Ghazala, West Cumberland Hospital, Whitehaven

Dr D.A. Smith & Dr G.U.A. Igboaka, Wansbeck District General Hospital, Ashington, Northumberland

Dr J.W. Lowe, Dr B. Naylor, Dr D. Gouldesbrough, Dr P.A. Batman, Bradford Royal Infirmary

Dr G.D.H. Thomas & Dr K. Shorrock, Royal Halifax Infirmary

Dr H.H. Ali & Dr M. Cassidy, Huddersfield Royal Infirmary

Dr L.A. Fenton & Dr P. Gudgeon, Dewsbury & District Hospital, West Yorkshire

Professor M.A. Greene, Dr J.C. Clark & Dr C.M. Milroy, Dept of Forensic Pathology, University of Sheffield

Prof J.C.E. Underwood, Dr T. McCulloch & Dr S.S. Cross, Royal Hallamshire Hospital, Sheffield

Dr J.R. Shortland, Northern General Hospital, Sheffield

Dr J.A. Coup, Barnsley District General Hospital

Dr A.W. MacDonald, Hull Royal Infirmary

Dr J.R. Read, Dr P.A. Burgess & Dr H.P.R. Bury, Castle Hill Hospital, Cottingham, North Humberside

Dr G. Kurien & Dr C. Hunt, Scunthorpe General Hospital

Dr C. Gray, Harrogate General Hospital

Dr A.T. Edwards & Dr A. Gledhill, Harrogate District Hospital

Dr J.J. O'Dowd & Dr R.D. Pyrah, Airdale General Hospital, Keighley

Dr I.N. Reid, York District Hospital

Dr J.B. Kershaw & Dr W.M. Peters, Grimsby District General Hospital

Dr D.C. Henderson & Dr K.V. Prasad, Friarage Hospital, Northallerton

Dr A.M. Jackson, Scarborough Hospital

Dr J. Burns, Dr J.R. Gosney, Dr C.P. Johnson, Dr T.R. Helliwell, Dr J. Nash, Dr B. Green & Dr R. Dixon, Royal Liverpool University Hospital

Dr W. Taylor, Dr C.T. Burrow, Dr T.E. Giles, Dr J.D.H. Sheard & Dr M.T. Haqqani, Fazakerley Hospital, Liverpool

Dr W.E. Kenyon & Dr M.W. Myskow, Broad Green Hospital, Liverpool

Dr M.S. Al‐Jafari, Walton Hospital, Liverpool

Professor A.J. Freemont, Manchester Royal Infirmary

Dr N.Y. Habouri, Withington Hospital, Manchester

Dr D.M.H. De Kretser, North Manchester General Hospital Dr P.S. Hastleton, Dr E. Sim, Dr H.M. Doran & Dr P.W. Bishop, Wythenshawe Hospital, Manchester

Dr G.R. Armstrong, Dr D.A. Agbamu, Dr R.J. Byers, Dr R.S. Reeve & Dr A.W. Jones, Hope Hospital, Salford, Greater Manchester

Dr J.M. Torry & Dr I. Gupta, Leigh Infirmary, Greater Manchester

Dr M.B. Reid & Dr N.E. New, Royal Albert Edward Infirmary, Wigan

Dr S. Wells, Dr G. Morphopoulos & Dr D.L. Bisset, Bolton General Hospital

Dr R.J. Farrand, The Royal Infirmary, Bolton

Dr D.M. Vickers, Dr A.J. Yates & Dr R.J. Hale, Stepping Hill Hospital, Stockport

Dr D.L. Bee & Dr A.S. Day, Tameside General Hospital, Ashton‐under‐Lyme

Dr B.N.A. Hamid & Dr M.Y. Sheikh, Trafford General Hospital, Manchester

Dr M.W. Atkinson & Dr I. Seddon, The Royal Oldham Hospital

Dr R. Menon & Dr M.G. Bradgate, Birch Hill Hospital, Rochdale

Dr M.E. Herd, Dr S. Dutt, Dr G. Garrett, Dr A.J. Yates, Dr W. Lawer & Dr S.S. Hom‐Choudhury, Fairfield General Hospital, Bury

Dr A.J. Howat, Dr E. Tapp, Dr C.M. Nicholson & Dr P.G. Lynch, Royal Preston Hospital

Dr V. Tagore, Ormskirk & District General Hospital

Dr H.D. Zakhor, Arrowe Park Hospital, Wirral

Dr W.D. Salman & Dr A.A.F. AI‐Dawoud, Burnley General Hospital

Dr H.M. Myat, Rossendale General Hospital, Lancashire

Dr Quereshi, Nelson Mortuary, Pendle, Lancashire

Dr J.A. Morris, Dr D.H. Orrell, Dr M. Stewart & Dr R.W. Blewitt, Westmoreland General Hospital, Kendal & Royal Lancaster Infirmary

Dr K.S. Vasudev, Dr M.C.J. Sissons & Dr J. Edwards, Victoria Hospital, Blackpool

Dr D. Semeraro, Dr C.S. Holgate, Dr I.P. Hopper & Dr J. Cocker, Derby Royal Infirmary

Dr J.V. Clark, Dr A.J. Molyneux & Dr S.B. Coghill, Northampton General Hospital

Dr B.E. Gostelow, Dr J.A.H. Uraiby, Dr L.E. Pirie & Dr S.R. Milkins, Kettering General Hospital

Dr P.B. Gray, Dr S. Rogers & Dr S.S. Cross, Chesterfield & North Derbyshire Royal Hospital

Dr D.C. Bouch, Dr K.P. West & Dr C.H. Kendall, Leicester Royal Infirmary

Dr S.M. Shah & Dr D.C.S. Durrant, Pilgrim Hospital, Boston

Dr D.M. Clark, Grantham & Kesteven General Hospital

Dr T.A. French & Dr C.R. Knappett, Central Pathology Laboratory, Stoke‐on‐Trent

Dr C. Musgrove, Dr J.C. Broome & Dr M. Stephens, North Staffordshire Royal Infirmary, Stoke‐on Trent

Dr P. Kitara‐Okot, City General Hospital, Stoke‐On‐Trent

Dr J.L. Christie, Dr O.P.R. Stores, Dr T. Hollingworth & Dr S. Ghosh, Russells Hall Hospital, Dudley, West Midlands

Dr K.W.M. Scott, The Royal Hospital, Wolverhampton

Dr K.J. Holley, Dr E.J. Vella & Dr K.M. Newbold, South Warwickshire Hospital, Warwick

Dr J.F. Nottingham, Hospital of St Cross, Rugby, Warwickshire

Dr N.M.S. Bajallan, George Eliot Hospital, Nuneaton

Dr T.G. Ashworth, Dr K. Chen & Dr T. Guha, Walsgrave Hospital NHS Trust, Coventry

Dr J.C. Macartney, Dr L. Brown & Dr G.H. Eeles, Alexandra Hospital, Redditch

Dr G.M. Kondratowicz, Kidderminster General Hospital

Dr J. Simon & W.J. Fuggle, Sandwell District General Hospital, West Bromwich

Dr P.E. Nicholls, Dr P.W. Leedham, Dr R.A. Fraser, Dr T.J. Jones, Royal Shrewsbury Hospital and Princess Royal Hospital, Wellington, Telford

Dr J.S. Dinnen & Dr F. McGinty, County Hospital, Hereford

Dr D.G.D. Wight, Dr J. Arno, Dr N. Coleman, Dr I. van Lijnschoten, Dr A.M. Goddard & Dr S. Thiru, Addenbroke's Hospital, Cambridge

Dr S. Stewart, Papworth Hospital, Cambridge

Dr T.H.W. Barker, Dr R.N. Lonsdale, Dr R.Y. Ball, Dr B.G. McCann & Dr P.F. Roberts, Norfolk & Norwich Hospital

Dr R.G.G. Rowe, Dr P.A. Judd, Dr J.E. Trowell & Dr J.M. Orrell, Ipswich Hospital

Dr D.A. Harrison, Dr M.J. Wilkinson & Dr N.J. Ball, James Paget Hospital, Great Yarmouth

Dr H.K. Al‐Rufiae & Dr T. Biedrzcki, West Suffolk Hospital, Bury St Edmonds

Dr M.D. Harris, Dr A.L. Whitehead & Professor G.A. Gresham, Hinchingbrooke Hospital, Huntingdon

Dr D. Eakins & Dr R.A. Eames, Queen Elizabeth Hospital, Kings Lynn

Dr M. Lesna, Dr D.M. Parham, Dr S.S. Quereshi & Dr A. Connoly, Royal Bournemouth Hospital

Dr D.S. Nicholas & Dr J.H.P. Alexander, Poole General Hospital

Professor P.P. Antony, Royal Devon & Exeter Hospital (Wonford)

Dr T.J. Clarke, Dr R.H.W. Simpson & Dr D.S. Arora, Area Department of Pathology, Exeter

Dr W.L.H. Scarrat, Dr AJ Sherwood & Dr D.M. Lee, Derriford Hospital, Plymouth

Dr A.M. Anscombe, Dr M.C.F. Jenkins & Dr L. Machin, Dorset County Hospital, Dorchester

Dr L. Daborn, West Dorset Hospital, Dorchester

Dr R.W. Pitcher, Dr R.J. Marshall & Dr Y. Sivathondan, Royal Cornwall Hospital (Treliske), Truro

Dr N.A. Shepherd, Dr B.W. Colding & Dr J.S. Uff, Gloucester Royal Hospital

Dr J.P. Sheffield, Yeovil District Hospital

Dr E.W. Hall, Dr C.B. Hobbs, Dr T.I.F. MacLeod & Dr J.V. Lever, Royal United Hospitals, Bath

Dr N. Gubbay, Cheltenham General Hospital

Dr B.M. Hill, Dr D.E. Fish, Dr A.J. Rainey & Dr M. Ameen, East Surrey Hospital, Redhill

Dr R.W. Ainsworth, Dr N.G. Ryley & Dr M.G. Cook, Royal Surrey County Hospital, Guilford

Dr M. Hall & Dr N.A. Ratcliffe, St Peter's Hospital, Chertsey, Surrey

Dr B. Bramble & Dr S. Ibrahim, Ashford Hospital, Middlesex

Dr J.B. Stewart, Dr T.J. Matthews & Dr L.N. Temple, Epsom General Hospital

Professor D.A.L. Bowen, Charing Cross Hospital, London

Dr D. Shove, Finchley Public Mortuary, London

Dr R.C. Chapman & Dr V. Djurovic, Guy's Hospital, London

Dr M.R. Crompton, St George's Hospital Medical School, London

Dr J.L. Dyson, Dr W. Thurrell & Dr D.C. Brown, Wittington Hospital, London

Dr J.E. McLaughlin & Dr A.J. Maddox, Royal Free Hospital, London

Professor N. Woolf, Middlesex Hospital, London

Dr M.J. Heath, Dr P.A. Lannas & Dr D.A. Rouse, The London Medicolegal Centre

Dr I.E. West & Dr F. Patel, Guy's Hospital, London

Dr G.N. Soosay, King George Hospital, Ilford, Essex

Dr N.J.E. Marley, Dr D.A. McCormick & Dr R. Buchanan, St. Mary's Hospital, Portsmouth

Dr R. Coddington & Dr J.D. Buchanan, Haslar Royal Naval Hospital, Gosport

Dr M.J. Jeffrey, Dr J.J. Mikel, Dr D. Madziwa, Dr T. Beer & Dr M.I.J. Andrews, Queen Alexandra Hospital, Portsmouth

Dr P.J. Gallagher, Dr A. Hitchcock, Dr D. Ellison, Dr J.M. Theaker, Dr W.R. Roche, Dr A. Bateman, Dr G. Culora & Professor D.H. Wright, Southampton General Hospital

Dr G.H. Millward‐Sadler, Dr A.D. Ramsey & Dr C.E.H. DuBoulay, Lymington Hospital, Hampshire

Dr D.B. Rimmer & Dr A.J. Blackshaw, Bedford Hospital (South Wing)

Dr D.A.S. Lawrence, Dr M. Nayagam & Dr J. Dove, Luton & Dunstable Hospital

Dr P.R. Millard, John Radcliffe Hospital, Oxford

Dr N.J. Mahy & Dr G. Greywood, Horton General Hospital, Banbury

Dr M.J. Turner & Dr Y. Chia, Wycombe General Hospital, High Wycombe, Buckinghamshire

Dr E.M. Husband & Dr J.M. Finch, Basingstoke District Hospital

Dr C.E.T. Smith & Dr J.S. Haldane, Frimley Park Hospital

Dr N. Greenwood, Dr L.H. Kissen & Dr R. Joshi, St. Mary's Hospital, Newport, Isle of Wight

Dr R.G.M. Letcher, Dr K.J. Agarwal & Dr J. McKenzie, St. Margaret's Hospital, Epping

Dr A. Fattah & Dr M.S.S. Al‐Izzi, Queen Elizabeth II Hospital, Welwyn Garden City


We are grateful to the coroners (listed in Appendix B) and coroner's pathologists (Appendix C) for their participation. We also thank the Clinical Epidemiology and Histopathology Staff at the National Heart and Lung Institute and Royal Brompton & National Heart Hospital: S. Lawlor, R. Florio, N.R. McLennan, J.E. Ingham, P.F. Daniel and R. Valay. This survey was funded by the British Heart Foundation.


  • Address correspondence to Dr T.J. Bowker, Cardiovascular Medicine, National Heart & Lung Institute at Charing Cross Campus, Imperial College, London. e‐mail: bowkert{at}bhf.org.uk.


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