Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 1 May 2020 and registered up to 9 May 2020 (provisional)

• Since the beginning of the coronavirus (COVID-19) pandemic (between the period 2 March and 1 May 2020, registered up to the 9 May 2020) there were 45,899 deaths of care home residents (wherever the death occurred); of these 12,526 involved COVID-19, which is 27.3% of all deaths of care home residents.

• Of deaths involving COVID-19 among care home residents, 72.2% (9,039 deaths) occurred within a care home, and 27.5% (3,444 deaths) occurred within a hospital.

• Of all deaths in hospital from 2 March 2020 involving COVID-19, 14.6% were accounted for by care home residents.

• Between the period 2 March and 1 May 2020, registered up to the 9 May 2020, COVID-19 was the leading cause of death in male care home residents, accounting for 30.3% deaths, and the second leading cause of death in female care home residents, after Dementia and Alzheimer disease, accounting for 23.5% of deaths.

• Dementia and Alzheimer disease was the most common main pre-existing condition found among deaths involving COVID-19 and was involved in 42.5% of all deaths of care home residents involving COVID-19.

• The Care Quality Commission collect information on recipients of domiciliary care in England, between 10 April 2020 and 8 May 2020 there were 3,161 deaths of recipients of domiciliary care, this was 1,990 deaths higher than the three-year average (1,171 deaths).

• The provisional number of deaths of care home residents occurring in England and Wales from 28 December 2019 to 1 May 2020, registered up to 9 May 2020, was 73,180; of these 12,526 involved COVID-19.

The term "care home residents" used in this article refers to all deaths where either (a) the death occurred in a care home, or (b) the death occurred elsewhere but the place of residence of the deceased was recorded as a care home. The figures should not be confused with "deaths in care homes" as reported in other publications, which refers only to category (a).

This article contains detailed analysis of all deaths of care home residents that occurred in England and Wales where the coronavirus (COVID-19) was involved. Some information on deaths of recipients of domiciliary care, living in private homes, is also provided.

Please note that the figures presented within this article are based on the date a death occurred and not the date a death was registered. Therefore, figures may differ from those published in the Deaths registered weekly in England and Wales publication.

Between 28 December 2019 and 1 May 2020, there were 73,180 deaths of care home residents that occurred in England and Wales and were registered by 9 May 2020.

Our definition of deaths involving COVID-19 includes cases where the certifying doctor suspected the death involved COVID-19 but was not certain, for example, because a test was not undertaken. Of the 12,526 deaths involving COVID-19 of care home residents, 11,371 were classified as "confirmed" COVID-19 and 1,155 (9.2%) were classified as "suspected" COVID-19.

In this article, we use the term "due to COVID-19" when referring only to deaths with an underlying cause of death as COVID-19, and we use the term "involving COVID-19" when referring to deaths that had COVID-19 mentioned anywhere on the death certificate, whether as underlying cause or not.

The provisional number of deaths in care home residents occurring in England and Wales from 28 December 2019 to 1 May 2020 (registered up to 9 May 2020) was 73,180; this represents 23,136 more than the same period last year. Of these deaths, 12,526 mentioned "novel coronavirus (COVID-19)", which is 17.1% of all deaths in care home residents in the year-to-date. We are looking into excess of non-COVID-19 deaths and will be publishing more on this soon.

To improve the timely availability of data on deaths that involved COVID-19 in care homes, the Office for National Statistics (ONS) and the Care Quality Commission (CQC) and the Care Inspectorate Wales (CIW) have agreed to publish provisional counts of deaths of care home residents in care homes in England and Wales respectively, based on statutory notification by care home providers. More information can be found in Measuring the data section.

Figure 2: In England, the number of deaths among care home residents has increased in comparison with last year

The cumulative number of deaths of care home residents involving COVID-19, England, from 28 December 2019 to 1 May 2020, registered up to 9 May 2020

Notes:

1. All Office for National Statistics (ONS) figures for 2020 are provisional.
2. The ICD-10 definitions for the coronavirus (COVID-19) are U07.1 and U07.2.
3. Figures are for deaths that the Care Quality Commission (CQC) is notified of on the days specified. Figures only include deaths that were notified by 1 May 2020, and they may be an underestimate because of reporting delays.
4. To allow day-by-day comparisons to be made between 2020 and 2019, the date 29 February 2020 has been removed from this chart.

Data download

Up to 1 May 2020, there were 69,851 deaths among care home residents notified to the CQC. The ONS has reported that there were 69,709 deaths in care home residents in England occurring in the same period that were registered by 9 May 2020. The 10 April 2020 was the first day when data were collected using CQC's new method of identifying deaths involving COVID-19. Since then there have been 12,409 deaths involving COVID-19 notified to the CQC up to 8 May 2020.

An important difference between the two sources is that the ONS reports deaths where COVID-19 was mentioned on the death certificate, while CQC notifications rely on the statement of the care home provider that COVID-19 was suspected or confirmed. CQC does not hold person-level information that allows a direct comparison between the two sources and so an accurate effect of different reporting criteria cannot be determined. More information can be found in this joint statement.

Figure 3: In Wales, the number of deaths among care home residents has increased in comparison with last year

The cumulative number of deaths of care home residents involving COVID-19, Wales, from 28 December 2019 to 1 May 2020, registered up to 9 May 20

Notes:

1. All Office for National Statistics (ONS) figures for 2020 are provisional.
2. The ICD-10 definitions for the coronavirus (COVID-19) are U07.1 and U07.2.
3. Figures are for deaths that the Care Inspectorate Wales (CIW) is notified of on the days specified. Figures only include deaths that were notified by 1 May 2020, and they may be an underestimate because of reporting delays.
4. To allow comparisons to be made between 2020 and 2019, the date 29 February 2020 has been removed from this chart.

Data download

In Wales, the Welsh Government publishes the number of deaths of care home residents involving COVID-19 notified to the Care Inspectorate Wales (CIW). Any death involving COVID-19 was notified to the CIW from 16 March 2020 where suspected or confirmed COVID-19 was listed as the cause of death by the service provider. CIW data includes deaths in regulated care home settings, whereas ONS figures include a broader range of settings.

Including deaths notified up to 1 May 2020, there were 3,206 total deaths of care home residents notified to the CIW. The ONS has reported that there were 3,445 deaths of care home residents in Wales occurring in the same period that were registered by 9 May 2020. In Wales, the CIW has reported a total of 504 deaths involving COVID-19 up to 8 May 2020.

During 2019 care home services were undergoing re-registration with CIW due to new legislation, which introduced a new method of notifying CIW of deaths of care home residents. This may have resulted in some disruptions to notifications being submitted.

When looking at the regions of England, the highest number of deaths involving the coronavirus (COVID-19) in care home residents was in the South East with 2,109 deaths. However, London had the highest proportion of deaths involving COVID-19 accounting for 25.7% of deaths in care home residents. The South West had the lowest proportion of deaths involving COVID-19 accounting for 12.9% of deaths in care home residents. When comparing Wales with the English Regions, it had the lowest number (532) of deaths involving COVID-19 among care home residents.

This section looks at the proportion of deaths involving the coronavirus (COVID-19) accounted for out of all deaths among care home residents in each age group. Data are from since the beginning of the coronavirus pandemic and include deaths occurring from 2 March 2020 to 1 May 2020, registered up to 9 May 2020.

From 2 March 2020 to 1 May 2020 (registered up to 9 May 2020), 27.3% of all deaths occurring in care home residents involved COVID-19. When broken down by sex, this was 31.4% of all deaths of male care home residents and 24.5% of all deaths of female care home residents. When looking at the proportion by age group, the highest proportion of deaths involving COVID-19 was for those in the 65 to 69 years age group in both male and female care home residents, accounting for 35.1% and 30.3% respectively. The smallest percentage of COVID-19-related deaths in both male and female care home residents was in those aged 90 years and over, accounting for 28.2% and 21.5% respectively.

Figure 6 presents the age-specific mortality rates for deaths in care home residents in England involving COVID-19. These are a better measure of mortality than the number of deaths, as they account for the population size and age structure. They are also better for comparing between areas and over time.

Adjusting for the size and age structure of the population, there were 3,270.9 deaths from all causes per 100,000 for male care home residents and 2,157.1 deaths per 100,000 for female care home residents in England. The mortality rate for deaths involving COVID-19 for males (1,078.8 per 100,000 care home residents) was significantly higher than for females (607.0 per 100,000). In general, males have a higher mortality rate than females.

In England, the age-specific mortality rate was at least 6.5 times higher for care home residents aged 85 and over (persons) than for non-care home residents for deaths involving COVID-19 and for all deaths. It should be noted that a higher mortality is to be expected among care home residents than non-care home residents, even taking age into account, since poor health or frailty is a common reason for needing residential care.

Looking at the age-specific mortality rate for both male and female care home residents (Figure 6), mortality rates increased consistently with age. In each group, males had a higher age-specific mortality rate than females. The difference was significant in all age groups 65 years and older.

The age group 85 years and over had the highest age-specific mortality rate for both males (5,771.1 per 100,000 people) and females (2,607.5 per 100,000 people), with 7,057 deaths involving COVID-19 occurring overall in this age group.

At the time of publication rates could not be calculated for Wales because of differences in the care home population. We are looking into this and will provide rates for care home residents in Wales in a future publication.

Of deaths involving the coronavirus (COVID-19) among care home residents (date of death from 2 March 2020 up to 1 May 2020, registered up to 9 May 2020), 72.2% (9,039 deaths) occurred within a care home, with the remainder occurring in hospitals (27.5%) or elsewhere (0.3%). Of all hospital deaths involving COVID-19, 14.6% were accounted for by care home residents.

At the beginning of the coronavirus pandemic, more deaths involving COVID-19 among care home residents occurred within the hospital setting. However, deaths within care homes increased more rapidly, and deaths within care homes became more prevalent from the start of April 2020.

The Office for National Statistics's (ONS's) leading causes of death groupings are based on a list developed by the World Health Organization (WHO). This categorises causes of death using the International Classification of Diseases, Tenth edition (ICD-10) into groups that are epidemiologically more meaningful than single ICD-10 codes, for the purpose of comparing the most common causes of death in the population.

Figure 9 shows the top five underlying causes of death occurring among care home residents from 2 March 2020 to 1 May 2020 and compares them to the same causes within the general population.

Dementia and Alzheimer disease was the underlying cause of death with the most deaths (13,418 deaths) in care home residents. When split out by sex, COVID-19 was the leading cause of death for males, accounting for 30.3% of deaths to male care home residents, and this is in line with the pattern in the general population.

For females, Dementia and Alzheimer disease was the leading cause of death, accounting for 32.9% of deaths, while COVID-19 was the second leading cause of death, accounting for 23.5% of deaths to female care home residents. This contrasts with the pattern for the general population where COVID-19 was the leading cause of death in females.

COVID-19 was the leading cause of death in male care home residents for all age groups. COVID-19 was also the leading cause of death for female care home residents aged under 80 years, but for those aged 80 years and over Dementia and Alzheimer disease was the leading cause of death.

To determine if there are any differences in the place of death for care home residents this year (deaths occurring from 2 March 2020 to 1 May 2020, registered up to 9 May 2020) in comparison with the same period last year, we have plotted the place of death per leading cause of death (Figure 10).

For all leading causes of death, there were more deaths in care homes in 2020 in comparison with the same period in 2019. Furthermore, this year there have been fewer deaths in hospitals to care home residents in comparison with 2019. This is consistent across all the leading causes of death examined.

The biggest difference in place of death of care home residents is evident in Ischaemic Heart Disease (IHD). The proportion of deaths due to IHD that occurred between 2 March and 1 May 2020 (registered up to 9 May 2020) in a care home was 91.1%, compared with 78.9% for the same period in 2019. In 2019, more deaths (20.9%) due to IHD occurred within a hospital setting in comparison with 2020 (8.7%).

We define a pre-existing condition as any health condition mentioned on the death certificate that either came before the coronavirus (COVID-19) or was an independent contributory factor in the death. Where only COVID-19 was recorded on the death certificate, or only COVID-19 and subsequent conditions caused by COVID-19 were recorded, we refer to these deaths as having "No pre-existing conditions". We have data available for pre-existing conditions from 2 March 2020 to 1 May 2020 but registrations only up to 4 May 2020.

Here, we analyse deaths involving COVID-19 among care home residents by the main pre-existing condition. This is defined as the one pre-existing condition that is, on average, mostly likely to be the underlying cause of death for a person of that age and sex had they not died from COVID-19. For more detail on how pre-existing conditions and main pre-existing conditions are derived, please see Measuring pre-existing health conditions in death certification - deaths involving COVID-19.

Figure 11 shows the proportion of deaths involving COVID-19 with five main pre-existing cause groups, for males and females. Of the 12,047 care home resident deaths involving COVID-19, 10,727 (89.0%) had at least one pre-existing health condition. The mean number of pre-existing conditions was 2.0.

The most common, main pre-existing health condition in care home residents was Dementia and Alzheimer disease, with 5,115 deaths (42.5% of all deaths involving COVID-19).

The Care Quality Commission (CQC) collects notifications of deaths of people in receipt of domiciliary care, that is, care provided in a private home by a home care agency registered with CQC. The needs of people using the services may vary greatly, but packages of care are designed to meet individual circumstances. The person is visited at various times of the day or, in some cases, care is provided over a full 24-hour period. Where care is provided intermittently throughout the day, the person may live independently of any continuous support or care between the visit.

Providers are required to notify the CQC of a death where the person died while a regulated activity was being provided, or where their death may have been a result of the regulated activity or how it was provided. More information regarding notifications from providers can be found on the CQC's website.

From 10 April 2020 (when data are first available) to 8 May 2020, there were 3,161 deaths of recipients of domiciliary care in England, this is 1,990 deaths higher than the three-year average (1,171 deaths) for the same time period. Of the 3,161 deaths to home care residents, 593 (18.8%) of these involved COVID-19. This is lower than the 43.7% of deaths involving COVID-19 among care home residents notified to the CQC for the same time period. 

The Care Inspectorate Wales (CIW) do not hold information on deaths in domiciliary care services as these services are not legally required to notify CIW of deaths. The ONS data do not contain information on whether a person was in receipt of domiciliary care, so no direct comparisons are possible.

Coronaviruses

The World Health Organization (WHO) defines coronaviruses as "a large family of viruses that are known to cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). Between 2001 and 2018, there were 12 deaths in England and Wales because of a coronavirus infection, with a further 13 deaths mentioning the virus as a contributory factor on the death certificate.

Coronavirus (COVID-19)

COVID-19 refers to the "coronavirus disease 2019" and is a disease that can affect the lungs and airways. It is caused by a type of coronavirus. Further informationis available from the WHO.

Pre-existing condition

A pre-existing condition is defined as any condition that either preceded the disease of interest (for example, COVID-19) in the sequence of events leading to death or was a contributory factor in the death but was not part of the causal sequence.

More quality and methodology information on strengths, limitations, appropriate uses, and how the data were created is available in the Mortality statistics in England and Wales QMI.

To meet user needs, we are providing more information alongside our usual Deaths registered monthly in England and Wales dataset. This information is presented by sex and age group. We are also presenting age-specific mortality rates for recent time periods and breakdowns of deaths involving the coronavirus (COVID-19) by associated pre-existing health conditions.

The information used to produce these statistics is based on details collected when certified deaths are registered with the local registration office. The counts of deaths from specific conditions are updated with each weekly publication as the coding of the underlying cause is not always complete at the time of production. The doctor certifying a death can list all causes in the chain of events that led to the death and pre-existing conditions that may have contributed to the death. Using this information, we determine an underlying cause of death. More information on this process can be found in our user guide. 

In England and Wales, deaths should be registered within five days of the death occurring, but there are some situations that result in the registration of the death being delayed. For example, when a death needs to be investigated by a coroner. Therefore, there may be some deaths involving COVID-19 that have occurred but are yet to be registered, meaning they will not be included in this analysis.

Figures on deaths published by the Office for National Statistics (ONS) differ from those produced by the Department of Health and Social Care (DHSC) and the UK's public health agencies for two main reasons: the time between death and reporting of the death and the ONS's wider inclusion criteria. Our blog Counting deaths involving the coronavirus (COVID-19) helps to explain the differences.

Deaths involving COVID-19 are reported for each week in our Deaths registered weekly in England and Wales, provisional release. The weekly numbers reported as "occurring" change over time, as more deaths are registered that happened in past weeks. Unlike most ONS publications on deaths, this article is based on occurrence (date of death), not date of registration.

Care Quality Commission (CQC)

To improve the timely availability of data on deaths in care homes caused by COVID-19, the ONS and the Care Quality Commission (CQC) have agreed to publish provisional counts of deaths of care home residents in care homes in England, based on statutory notification by care home providers to the CQC.

The CQC is the independent regulator of health and social care in England. Notifications about deaths in care homes must be sent to the CQC without delay and are typically provided within two to three days of death. The data provided by the CQC are counts of deaths each day of care home residents who died in care homes, by date of notification. The data are from 10 April 2020 when CQC introduced a new method to understand whether COVID-19 was involved in the death.

A death involving COVID-19 is based on the statement from the care home provider to the CQC: the assessment of whether COVID-19 was involved may or may not correspond to a medical diagnosis or test result or be reflected in the death certification. More information on the data provided by the CQC can be found in our joint transparency statement. As with ONS registrations, reduced numbers of notifications occur on the weekend.

Care Inspectorate Wales (CIW)

In Wales, the Welsh Government publishes the number of deaths of care home residents involving suspected or confirmed COVID-19 notified to the Care Inspectorate Wales (CIW).

Data are collected on a daily basis through an online form developed and maintained by the Care Inspectorate Wales. The data are validated against previous returns and any significant changes are queried. Data include all notifications up to midnight each day. The data collection covers residents of adult care homes.

Care homes are required to notify the CIW of the location of death and cause of death. Prior to 29 April 2020, this was done through a free text box and the CIW have used manual searches on the data to produce summaries by category. From 29 April 2020, the form has been amended to include mandatory tick box categories for COVID-19 Confirmed or Suspected and location (hospital, care home, hospice, ambulance, other). Therefore, there is a change to the methodology used to produce these figures from 29 April 2020.

In terms of "Confirmed" COVID-19, from 29 April 2020 onwards, this has been provided to the CIW by the care home provider by means of an answer to the question: "Was the death a result of confirmed COVID-19?".

Prior to this date, the care home provider was not asked this question and so "Confirmed" for these is where the CIW's inspectors have reviewed the free text data provided by the care home provider (on the questions "cause of the person's death, if known and confirmed by a medical practitioner" and "summary of the circumstances leading up to the persons death and all contributing factors") and determined that it relates to a confirmed case.

In both scenarios the CIW are reliant on the care home provider to inform them appropriately of a confirmed case.

The ONS uses a broader definition of care home residents than that used in the CIW data.

An important difference between the three sources (ONS, CQC, CIW) is that the ONS reports deaths where COVID-19 was mentioned on the death certificate, while the CQC and CIW notifications rely on the statement of the care home provider that COVID-19 was suspected or confirmed.

Differences in data can be caused by registration delays in the ONS figures or reporting delays in the CQC and CIW figures. It takes around two to three days for the CQC to be notified of a death, while the ONS has to wait until a death is registered to be included in our statistics, which can take longer. On average, there was a median delay of four days between a death occurring and being registered in care home residents, year-to-date. The CQC and CIW do not hold person-level information that allows a direct comparison between the two sources and so an accurate effect of different reporting criteria cannot be determined.

Table 1 provides an overview of the differences in definitions between sources.

There is usually a delay of at least five days between occurrence and registration. More information on this issue can be found in our impact of registration delays release.

Our User guide to mortality statistics provides further information on data quality, legislation and procedures relating to mortality and includes a glossary of terms.

Figures are based on the date the death occurred, not when it was registered. There is usually a delay of at least five days between occurrence and registration, so there may be some deaths that occurred in March 2020 that are not yet registered. More information on this issue can be found in our impact of registration delays release.

Provisional death registrations and death occurrences data are used in this bulletin. This enables timely analysis to be completed to monitor mortality trends. However, as the data are provisional, they are subject to change.

We have used the most up to date communal establishment file we have for both 2019 and 2020 data. Therefore, there is some potential for under and over coverage within the figures provided.