We reviewed 22,486 consecutive autopsy reports in a single District General Hospital, from 1953 to 1992. Five hundred and eighty-one patients with fractures of the proximal femur (hip fracture) were identified. Causes of death were correlated with timing of surgery and change of clinical practice. Thromboembolic and haemorrhagic potential were analysed. The principal causes of death after hip fracture were bronchopneumonia, cardiac failure, myocardial infarction and pulmonary embolism. Surgical intervention, within 24 h of injury significantly reduced death from bronchopneumonia and pulmonary embolism. Early mobilization reduced death from bronchopneumonia. Pulmonary embolism may be reduced by prophylactic anticoagulation, but 17 per cent of patients are at risk of haemorrhage, and mechanical methods seem safer in this population.