Deaths involving COVID-19, England and Wales: deaths occurring in March 2020

• There were 3,912 deaths involving the coronavirus (COVID-19) that occurred in March 2020 in England and Wales; of these, 3,372 (86%) had COVID-19 assigned as the underlying cause of death.
• Of the deaths involving COVID-19 that occurred in March 2020, there was at least one pre-existing condition in 91% of cases.
• Taking into account the age structure of the population, the rate of deaths due to COVID-19 was 68.5 deaths per 100,000 persons; this was 69.7 per 100,000 persons in England compared with 44.5 per 100,000 persons in Wales.
• COVID-19 was the third most frequent underlying cause of death for deaths occurring in March.
• Males had a significantly higher rate of death due to COVID-19; the rate was double that of females.
• The rate of death due to COVID-19 increased significantly in each age group, starting from age 55 to 59 years in males and age 65 to 69 years in females; overall, one in five deaths were in age group 80 to 84 years.
• Ischaemic heart disease was the most common main pre-existing condition found among deaths involving COVID-19 and was involved in 541 deaths (14% of all deaths involving COVID-19).

This article contains detailed analysis of all deaths that occurred in England and Wales between 1 and 31 March 2020, registered up to 6 April 2020, where the coronavirus (COVID-19) was involved. There are breakdowns by age and sex and the causes of death mentioned on the death certificate.

The information used to produce these statistics is based on details collected when certified deaths are registered with the local registration office. 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 occurred in March 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.

Between 1 and 31 March 2020, there were 47,358 deaths that occurred in England and Wales and were registered by 6 April 2020. Of these, 8% involved the coronavirus (COVID-19) (3,912 deaths). 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 the majority of cases (3,372 deaths, 86%) when COVID-19 was mentioned on the death certificate, it was found to be the underlying cause of death.

Our definition of COVID-19 includes some cases where the certifying doctor suspected the death involved COVID-19 but was not certain, for example, because no test was done. Of the 3,372 deaths with an underlying cause of COVID-19, 38 (1%) were classified as “suspected” COVID-19. Looking at all mentions, “suspected” COVID-19 was recorded on 1% of all deaths involving 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.

Figure 1 shows the age-standardised mortality rates (ASMRs) for deaths “involving” and due to COVID-19. ASMRs 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 countries and over time.

When adjusting for size and age structure of the population, there were 68.5 deaths per 100,000 people in England and Wales due to COVID-19 in March 2020. Taking into account all deaths involving COVID-19 increases the rate to 79.5 deaths per 100,000 people. The mortality rate for males (97.5 deaths due to COVID-19 per 100,000 people) was significantly higher than for females (46.5 deaths per 100,000 people). In general, males have a higher mortality rate than females.

Figure 2 presents the number of deaths with an underlying cause of death of COVID-19 that occurred on each day since 2 March 2020, the first date a COVID-19 death occurred. We have included deaths that were registered up to 6 April but occurred in March. Over time, as more deaths are registered, the number of cases that are known to have occurred in March will rise, especially for dates in the later part of the month.

Since 11 March 2020, the number of COVID-19 deaths occurring each day rose, with the exception of 23 March when it decreased by two deaths. Figure 2 also shows the number of deaths per day in March regardless of cause and the five-year average for each day. At the start of March, the number of deaths per day was below the five-year average, likely because of the mild winter and low levels of circulating flu. However, towards the end of the month, we can see that the number of deaths was above the five-year average. The increase in overall daily deaths coincides with the increase in daily deaths involving COVID-19.

The mortality rate in England was significantly higher than in Wales, at 69.7 deaths per 100,000 people compared to 44.5 deaths per 100,000 people.

This bulletin will focus on England and Wales combined, but all figures are presented in the accompanying data tables and are provided for England and Wales both combined and separately.

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 4 shows the top five underlying causes of death occurring in March 2020.

Dementia and Alzheimer disease was the underlying cause of death with the most deaths (6,401 deaths), accounting for 14% of all deaths occurring in March 2020. This was followed by Ischaemic heart diseases with 4,042 deaths (9%) and the coronavirus (COVID-19), with 3,372 deaths (7%).

There were significant differences in the mortality rates between each of the leading causes. COVID-19 had a mortality rate of 68.5 deaths per 100,000 people. Dementia and Alzheimer disease and Ischaemic heart disease were both significantly higher than death due to COVID-19, with 129.6 and 82.5 deaths per 100,000 people respectively. Chronic lower respiratory diseases and Cerebrovascular diseases were significantly lower, with 59.7 and 52.2 deaths per 100,000 people.

The March 2020 five-year average age-standardised mortality rate (ASMR) for each cause was higher than the rate for March 2020; this was significant for all causes apart from Dementia and Alzheimer disease.

There were no deaths in the three youngest age groups (those aged 0 to 14 years). The youngest age group to record a death was those aged 15 to 19 years, with one female death.

Looking at the age-specific mortality rate for both genders, the mortality rate increased consistently with age. In each age group where a rate was recorded, males had a higher age-specific mortality rate than females. This difference was significant in all age groups starting from those aged 55 to 59 years.

The age group 90 years and over had the highest age-specific mortality rate for both males (1,728.2 per 100,000 people) and females (840.9 per 100,000 people), with 527 deaths occurring overall in this age group. The mortality rate in this age group was significantly higher than all other ages for both sexes. The age-specific mortality rate due to the coronavirus (COVID-19) increased significantly in each age group, starting from ages 55 to 59 years in males and ages 65 to 69 years in females.

This section will look at the proportion COVID-19 deaths accounted for out of all deaths in each age group.

In March 2020, 7% of all deaths occurring were a result of COVID-19. When broken down by gender, this was 9% of all deaths for males and 6% for females. When looking at the proportion by age group, we can see that the highest proportion of deaths due to COVID-19 was in age group 75 to 84 years, with (9%) of all deaths in this age group having an underlying cause of COVID-19. Of those age groups with deaths due to COVID-19 recorded, those aged 85 years and over had the smallest percentage of deaths due to COVID-19, at 6% of all deaths in this age group.

For males, the age group that made up the highest proportion of COVID-19 deaths was those aged 80 to 84 years, with 21%. For females, the two oldest age groups (those aged 85 to 89 years and 90 years and over) made the joint-highest contribution, with 20% each. Overall, one in five deaths were in age group 80 to 84 years.

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 COVID-19 and subsequent conditions caused by COVID-19 were recorded, we refer to these deaths as having “No pre-existing conditions”.

Of the 3,912 deaths that occurred in March 2020 involving COVID-19, 3,563 (91%) had at least one pre-existing condition, while 349 (9%) had none. The mean number of pre-existing conditions was 2.7.

The most common main pre-existing condition was ischaemic heart diseases, with 541 deaths (14% of all deaths involving COVID-19). This may in part explain the decrease in deaths resulting from ischaemic heart diseases in March 2020, but this requires further analysis. Pneumonia, dementia and chronic obstructive pulmonary disease (COPD) were all in the top five most common pre-existing conditions.

Here, we analyse deaths involving COVID-19 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 the accompanying methodology article, Measuring pre-existing health conditions in death certification – deaths involving COVID-19.

The most common pre-existing conditions differed by age group. Figure 8 shows the proportion of deaths involving COVID-19 with six main pre-existing cause groups, for males and females aged 0 to 69 years and 70 years and over. For age groups younger than age 70 years, “No pre-existing conditions” ranks much higher than in those aged 70 years and over, where conditions such as dementia and Alzheimer disease are much more prominent.

“Chronic lower respiratory diseases” groups together asthma and COPD with other lower respiratory diseases. There were 20 deaths involving COVID-19 with a main pre-existing condition of asthma in males aged 0 to 69 years (4% of deaths involving COVID-19 for that group), 41 in males aged 70 years and over (2% of deaths involving COVID-19 for that group), 24 in females aged 0 to 69 years (8% of deaths involving COVID-19 for that group) and 38 in females aged 70 years and over (3% of deaths involving COVID-19 for that group).

The accompanying datasets provide breakdowns of the most common main pre-existing conditions for all persons, males and females by five-year age group from age 45 years onwards. This is to show how the rank of most common main pre-existing conditions changes with sex and age.

Ischaemic heart diseases, Chronic lower respiratory diseases, Influenza and pneumonia, and no pre-existing conditions feature the most across these age and sex breakdowns.

Deaths should normally be registered within five days of the date of death, but there are a number of situations where the registration of a death will be delayed.

This section looks at how long the deaths that occurred in March took to be registered. As there is a delay between death occurrence and death registration, we do not know the final number of deaths that occurred in March 2020 yet. The median registration delay may therefore increase as those deaths not registered yet but occurring in March 2020 are registered. More information on this issue can be found in our impact of registration delays release.

Figure 9 shows the median delay in days of death registration for deaths that occurred in March 2020 for all causes of death and for those involving the coronavirus (COVID-19). The median delay in registration was the same at four days for deaths involving COVID-19 and for all causes of death. The circles on the figure represent the spread of the registration delays for both COVID-19 and all causes of death in March 2020.

Figure 9: Median delay in registration was the same for COVID-19 deaths and all causes of death in March 2020

Based on deaths that occurred in March 2020, England and Wales

Source: Office for National Statistics – Analysis of deaths involving COVID-19

Download this image Figure 9: Median delay in registration was the same for COVID-19 deaths and all causes of death in March 2020

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Looking at the percentage of deaths registered within seven days of death, 82% of all deaths that occurred in March 2020 were registered within seven days, whereas 83% of deaths involving COVID-19 that occurred in March 2020 were registered within seven days.

Figure 10 looks at the age-standardised mortality rate (ASMR) for March 2020 as well as comparative figures for February 2020, March 2019, and March on average between 2015 and 2019.

It is important to note that the number of deaths for March 2020 and February 2020 are likely to increase as we receive more registrations. Currently, the rate of deaths occurring in March 2020 (964.5 per 100,000 people) is significantly higher than that of February 2020 (904.3 per 100,000 people) and March 2019 (928.6 per 100,000 people). The rate is significantly lower than the five-year average of March 2015 to 2019 (1,027.5 deaths per 100,000 people). This could, in part, be because of the colder winters experienced in 2015 and 2018, which led to a higher number of deaths in the winter months.

Age-specific mortality rates

Age-specific mortality rates are used to allow comparisons between specified age groups.

Age-standardised mortality rates

Age-standardised mortality rates (ASMRs) are used to allow comparisons between populations that may contain different proportions of people of different ages. The 2013 European Standard Population is used to standardise rates.

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 due to 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 information is 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.

Main pre-existing condition

The main pre-existing condition 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.

Registration delay

Mortality statistics are compiled from information supplied when deaths are certified and registered as part of civil registration, a legal requirement. According to the Births and Deaths Registration Act 1953, a death should be registered within five days unless it is referred to a coroner for investigation. Mortality statistics for a given time period can be based on occurrence (death date) or registration (registration date); registration delay is the difference between date of occurrence and date of registration.

Statistical significance

The term “significant” refers to statistically significant changes or differences. Significance has been determined using the 95% confidence intervals, where instances of non-overlapping confidence intervals between estimates indicate the difference is unlikely to have arisen from random fluctuation. In some circumstances, significance has also been tested using z scores.

More information about this z test is available in Appendix 1 of the Sullivan guide.

95% confidence intervals

A confidence interval is a measure of the uncertainty around a specific estimate. If a confidence interval is 95%, it is expected that the interval will contain the true value on 95 occasions if repeated 100 times. As intervals around estimates widen, the level of uncertainty about where the true value lies increases. The size of the interval around the estimate is strongly related to the number of deaths, prevalence of health states and the size of the underlying population. At a national level, the overall level of error will be small compared with the error associated with a local area or a specific age and sex breakdown. Therefore, the widths of the confidence intervals reported in this release will have sizable differences.

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 providing age-standardised mortality rates (ASMRs) and age-specific mortality rates for recent time periods and breakdowns of deaths involving the coronavirus (COVID-19) by associated pre-existing health conditions.

These figures are different from the daily surveillance figures on COVID-19 deaths published by the Department of Health and Social Care (DHSC) on the GOV.UK website, for the UK as a whole and its constituent countries. Figures in this report are derived from the formal process of death registration and may include cases where the doctor completing the death certificate diagnosed possible cases of COVID-19, for example, where this was based on relevant symptoms but no test for the virus was conducted. Our figures also include any deaths that occur outside hospital.

In contrast to the GOV.UK figures, we include only deaths registered in England and Wales, which is the legal remit of the Office for National Statistics (ONS). 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 that are not yet registered. More information on this issue can be found in our impact of registration delays release.