The coronavirus pandemic has caused hundreds of thousands of deaths across Europe, with many regions recording more fatalities than would have been expected before the crisis.
Sky News analysis of 700 sub-national regions, across 19 European countries, has found that this excess mortality has been unevenly distributed.
In 30 of those regions, the number of extra deaths was up to twice the amount usually expected for the period from the beginning of March to the beginning of May.
This accounts for around a third of the 200,000 additional people who died across all of the countries analysed during weeks 10 to 19.
Nine of those 30 areas were in the UK. The rest were in Spain, Italy and France, where there were two.
The Italian city of Bergamo, part of the Lombardy region in the north of the country, recorded the highest number of excess deaths of any area analysed.
Four times more people died during March and April than would have been expected according to its past average.
The Cremona Hospital in the region was overwhelmed by the number of patients and had to store bodies in a nearby church during the outbreak.
The excess mortality in seven out of the 12 provinces in Lombardy was double the number of expected deaths.
The number of deaths recorded was at least 50% more than the average in the remaining five regions.
Italy has been one of the hardest-hit countries during the pandemic, with deaths concentrated in the north.
In Spain, the centre of the country has suffered the most, although most of the Spanish regions have registered more deaths than the five-year average.
Madrid and the surrounding areas highly connected to the Spanish capital have recorded almost three times as many deaths than would have been expected.
Barcelona has registered double the amount of deaths compared to its five-year average.
London has been the worst-hit region in the UK, while areas in the North and North West have registered twice the number of expected deaths.
But more deaths have been recorded than expected in all the UK regions, with a third of them registering an increase of more than 50%.
The number of weekly registered deaths in England and Wales fell below the five-year average on 30 June for the first time since lockdown began, according to the Office for National Statistics (ONS).
Excess mortality refers to the number of deaths above the average recorded in a given area.
This is considered a better metric to assess the impact of coronavirus, as only those who died after testing positive for the disease or were suspected cases are registered as COVID-19 deaths.
However, people with serious conditions such as cancer or heart failure may also have died as a result of the pandemic because they chose not to visit hospitals that are under pressure from the virus.
Dr Bharat Pankhania, an infectious diseases expert at the University of Exeter, said it is important countries record excess deaths because the figures show the number of people dying both directly and indirectly as a result of the pandemic.
He told Sky News: “Healthcare services are being stretched because of the virus and so people may not be going to hospitals or presenting in time.
“People may not go to hospital because they’ve got chest pain, or they may not go because of their stroke, abdominal pain or cancer.
“So we end up with an excess deaths figure which indicates that this is also a part of the pandemic, in other words, the pandemic is not only killing people with infection, but it’s killing people as a result of it being present.”
The peak in mortality was registered between March and April in many of the worst affected countries.
However, national trends for some countries like the UK and Sweden show mortality was still high in May, which might be partly due to the later arrival of the virus in these countries.
The number of deaths registered in over 75-year-olds has been particularly high in Spain, where deaths in this group were 66% higher than expected.
In Italy, there were 43% more deaths than expected among 75-year-olds, while in England and Wales it was 52% and in Belgium it was 47%.
Dr Pankhania said one of the reasons excess deaths figures vary across Europe is because of the varying abilities of different healthcare services to cope with the pandemic.
He continued: “There could be multiple reasons why excess deaths in some countries are lower than in others.
“But essentially it is an indicator of the health services managing, or not managing that well, in the midst of a pandemic.”
Countries included in the analysis: Austria, Belgium, Bulgaria, Switzerland, Czech Republic, Germany, Denmark, Spain, Finland, France, Italy, Latvia, Luxembourg, Netherlands, Norway, Portugal, Sweden, Slovakia, United Kingdom.
The regional division used is the NUTS level 3 classification for all the countries, except Austria and Netherlands which used NUTS level 2. Data for Germany is not available by NUTS, but by Bundeslands.
Weeks included: 10 to 19 for all the countries, except for Czech Republic, Luxembourg and Slovakia for which the series ends in week 18.
Past average is calculated with data between 2015 and 2019 for most of the countries, except Italy and Germany (2016-2019) and the Netherlands (2017-2019).