Monthly mortality analysis, England and Wales: April 2022

• In April 2022, there were 42,944 deaths registered in England, 2,200 deaths (5.4%) above the April five-year average (2016 to 2019, and 2021); there were 2,894 deaths registered in Wales, 113 deaths (4.1%) above the April average.

• Compared with the 2015 to 2019 five-year average (as opposed to the new five-year average used in the previous main point), in April 2022 there were 1,522 more deaths (3.7%) in England, and 67 more deaths (2.4%) in Wales.

• The leading cause of death in England in April 2022 was dementia and Alzheimer's disease (10.9% of all deaths); in Wales, the leading cause was ischaemic heart diseases (12.6% of all deaths); these are the same causes as March 2022.

• Coronavirus (COVID-19) was the third leading cause of death in April 2022 for both England (accounting for 6.1% of all deaths) and Wales (5.7% of all deaths); it was the sixth leading cause in March 2022.

• The proportion of deaths due to COVID-19 (of all deaths that involved COVID-19) increased between March and April 2022 in England (from 63.0% to 64.2%) and Wales (from 64.3% to 65.1%).

• Accounting for the population size and age structure, the age-standardised mortality rate (ASMR) for deaths due to COVID-19 increased significantly between March and April 2022 in England (from 40.7 to 56.0 deaths per 100,000 people); the ASMR in Wales also increased but was not statistically significant (from 45.3 to 58.4 deaths per 100,000 people).

• The year-to-date (January to April) ASMR in 2022, in England, was significantly lower than all years since our time series began in 2001 (978.8 deaths per 100,000 people); in Wales, it was the lowest since 2014, but this difference was not statistically significant (1,067.5 deaths per 100,000 people).

• Yorkshire and The Humber continued to be the English region with the highest ASMR for deaths due to COVID-19 in April 2022 (66.7 deaths per 100,000 people).

Based on provisional data, there were 42,944 deaths registered in England in April 2022. This was 4,043 more deaths than in April 2021 and 2,200 more deaths (5.4%) than the five-year average (2016 to 2019, and 2021). Compared with the previous five-year average (2015 to 2019), there were 1,522 more deaths (3.7%) in April 2022 in England.

In Wales, the provisional number of deaths registered in April 2022 was 2,894. This was 332 more deaths than in April 2021 and 113 more deaths (4.1%) than the five-year average for April. Compared with the previous five-year average (2015 to 2019), there were 67 more deaths (2.4%) in April 2022 in Wales.

The five-year average for 2022 has been provided for 2016 to 2019 and 2021. This moves our five-year average along by a year but does not include the exceptionally high number of deaths seen in 2020. This is so that deaths in 2022 are compared with a five-year average that is up-to-date (rather than 2015 to 2019) while still being close to representing a usual (non-coronavirus (COVID-19) pandemic) year. For more information, see the Calculating excess deaths section.

Age-standardised mortality rates (ASMRs) are used for comparisons over time rather than numbers of deaths, because ASMRs account for changes to the population size and age structure.

In England, 2002 had previously been the year with the highest April mortality rate (at 1,303.2 deaths per 100,000 people), followed by overall mortality rates generally decreasing to 854.8 deaths per 100,000 people in April 2017. In April 2020 (when deaths due to COVID-19 reached their first peak), the ASMR was statistically significantly higher than all other years’ April ASMR (at 1,867.0 deaths per 100,000 people). The ASMR for April decreased significantly in 2021 to a low of 852.1 deaths per 100,000 people, before significantly increasing to 921.1 deaths per 100,000 people in April 2022. This pattern in ASMRs over time was similar in both males and females (Figure 1).

In Wales, mortality rates for April have generally decreased over time; from a high of 1,399.3 deaths per 100,000 people in April 2003, to 1,044.2 deaths per 100,000 people in April 2019. The lowest ASMR in this time series was in April 2011, at 976.6 deaths per 100,000 people. As observed in England, Wales had a statistically significant increase in ASMR in April 2020 (1,652.3 deaths per 100,000 people) compared with the previous year. This was because of the peak of the first wave of the COVID-19 pandemic. The ASMR significantly decreased in April 2021 (920.2 deaths per 100,000 people), before significantly increasing in April 2022 (1,016.8 deaths per 100,000 people). This pattern in ASMRs over time was similar in both males and females (Figure 1), however the ASMR for males in April 2022 (1,173.5 deaths per 100,000 males) was not significantly higher than in April 2021 (1,077.1 deaths per 100,000 males).

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 to mortality statistics.

March 2020 was when the first deaths involving coronavirus (COVID-19) were registered in England and Wales. Since March 2020, when COVID-19 was mentioned on the death certificate, it was the underlying cause of death in most cases (86.5% in England, 85.2% in Wales).

In England, April 2020 had the highest proportion of deaths involving COVID-19 that were also due to COVID-19 (95.2%), whereas March 2022 had the lowest proportion (63.0%). In Wales, April 2020 had the highest proportion of deaths involving COVID-19 that were also due to COVID-19 (94.1%), whereas June 2021 had the lowest proportion (42.9%). These proportions generally correspond with periods of low or high numbers of COVID-19 deaths in England and Wales.

The proportion of deaths due to COVID-19 (of all deaths involving COVID-19) increased between March and April 2022 in England (from 63.0% to 64.2%) and Wales (from 64.3% to 65.1%).

For more information on our definition of COVID-19 deaths, see the Measuring the data section.

Of the 42,944 deaths registered in April 2022 in England, 6.1% (2,618 deaths) were due to COVID-19, a larger proportion than in March 2022 (4.3%). Including all deaths involving COVID-19 (4,079 deaths), this percentage increased to 9.5% of all deaths in England.

In Wales, 5.7% of the 2,894 deaths registered in April 2022 were due to COVID-19 (166 deaths), a larger proportion than in March 2022 (4.2%). Including all deaths involving COVID-19 (255 deaths), this percentage increased to 8.8% of all deaths in Wales.

Mortality rates for deaths due to COVID-19

When adjusting for the size and age structure of the population, age-standardised mortality rates (ASMRs) for deaths due to COVID-19 in England for April 2022 showed statistically significant increases compared with March 2022 (Figure 3). The ASMR for deaths due to COVID-19 in England increased to 56.0 deaths per 100,000 people in April 2022 (compared with 40.7 deaths per 100,000 people in March 2022). In Wales, the ASMR increased to 58.4 deaths per 100,000 people in April 2022 (compared with 45.3 deaths per 100,000 people in March 2022); however, this was not significantly different.

In England, the ASMR for deaths due to COVID-19 significantly increased in April 2022 for both males (69.5 deaths per 100,000 males) and females (46.4 deaths per 100,000 females), compared with March 2022 (53.9 and 31.7 deaths per 100,000 males and females respectively).

In Wales, the ASMR for deaths due to COVID-19 in April 2022 increased for males (65.2 deaths per 100,000 males) and for females (55.0 deaths per 100,000 females), compared with March 2022 (59.2 and 35.8 deaths per 100,000 males and females respectively). However, neither of these differences were significant.

More information on mortality rates by sex is available in Tables 3a and 3b of our accompanying dataset.

Figures 4 and 5 show the 10 most common underlying causes of death (based on the leading causes of death groupings) registered in April 2022 for England and Wales respectively, compared with the five-year average for April (2016 to 2019, and 2021).

In England, dementia and Alzheimer's disease remained the leading cause of death in April 2022, with 99.8 deaths per 100,000 people (4,699 deaths). In Wales, ischaemic heart diseases remained the leading cause of death, with 127.1 deaths per 100,000 people (366 deaths).

In both England and Wales, coronavirus (COVID-19) was the third leading cause of death in April 2022 (2,618 deaths in England and 166 deaths in Wales). This was an increase from sixth leading cause of death in both England and Wales in March 2022.

In England in April 2022, 7 of the 10 leading causes of death were statistically significantly lower than the five-year average, and 1 of the 10 leading causes was not statistically significantly different than the five-year average. The mortality rate for symptoms, signs, and ill-defined conditions was statistically significantly higher than the five-year average for the tenth consecutive month in England (12.2% higher). This leading cause group includes mostly deaths with a code for "old age" but is also used for causes such as "frailty".

As in previous months, the mortality rate for deaths with an underlying cause of influenza and pneumonia was significantly lower in April 2022 than the five-year average for April (35.1% lower). This is likely, in part, owing to people continuing to follow coronavirus guidance, such as social distancing. These measures reduced the spread of infections such as influenza.

In Wales in April 2022, 2 of the 10 leading causes of death were statistically significantly lower than the five-year average and 7 of the 10 leading causes were not significantly different from the five-year average. As in England, the mortality rate for influenza and pneumonia was significantly lower than the five-year average for April 2022 (48.8% lower) in Wales.

Leading causes of death registered in the year-to-date

In the first four months (January to April) of 2022, the leading cause of death in England was dementia and Alzheimer's disease (111.8 deaths per 100,000 people). In Wales, the leading cause of death was ischaemic heart diseases (120.9 deaths per 100,000 people).

In England, the year-to-date COVID-19 mortality rate was statistically significantly lower than the top two leading causes of death (dementia and Alzheimer's disease and ischaemic heart disease), and statistically significantly higher than all other leading causes. Similarly, in Wales, the year-to-date mortality rates of deaths due to ischaemic heart diseases and dementia and Alzheimer's were statistically significantly higher than deaths due to COVID-19. However, deaths due to COVID-19 were not statistically significantly higher than all other leading causes.

More information on the 2022 year-to-date leading causes of death is available in Tables 11a and 11b of our accompanying dataset. More in-depth analysis of leading causes of death is available in our annual publication based on finalised mortality data.

There were 182,031 deaths registered in England and 12,091 in Wales during the first four months (January to April) of 2022.

To gain a better idea of year-to-year differences in mortality rates, we calculated year-to-date age-standardised mortality rates (ASMRs) based on deaths registered in January to April of each year from 2001 to 2022 (Figure 6). For England, the year-to-date ASMR for 2022 (978.8 deaths per 100,000 people) was statistically significantly lower than all years since our time series started in 2001.

For Wales, the year-to-date ASMR for 2022 was 1,067.5 deaths per 100,000 people, which was statistically significantly lower than all years since our time series began, except 2014 and 2019 (1,067.1 and 1,086.2 deaths per 100,000 people, respectively).

This release predominantly analyses age-standardised mortality rates (ASMRs) as it enables us to make comparisons across areas and time. This is because ASMRs account for changes in the population and its age structure.

Another useful measure is the number of excess deaths in a particular year. For excess deaths, we compare numbers and rates with a five-year average. This ensures that we are comparing like for like in terms of life expectancy, advances in healthcare, population size, and age structure. Averaging over five years removes the fluctuations seen year-on-year. Usually, we use the most recent five years; for example, we compared deaths in 2020 with the five-year average for 2015 to 2019.

Because of the coronavirus (COVID-19) pandemic, 2020 saw the second highest number of deaths since 1838. If this was used to calculate the five-year average, then the number of deaths in the five-year average would be abnormally high and would not be comparable to a "normal" (non-coronavirus pandemic) year.

The further we move away from 2019, the less robust the 2015 to 2019 five-year average becomes. The decision was made for 2022 to move to an average of the following five years: 2016, 2017, 2018, 2019 and 2021. This moves our five-year average along by a year but does not include the exceptionally high number of deaths seen in 2020. It allows deaths in 2022 to be compared with a five-year average that is as up-to-date as possible, while still being close to representing a "normal" year. However, this does include some COVID-19 deaths, especially at the start of the year when there was a COVID-19 wave.

In April 2022, when considering the 2016 to 2019 and 2021 five-year average, excess deaths in England were 2,200 above what we would expect in a "normal" year, compared with 1,522 when using the 2015 to 2019 average. The year-to-date (January to April) excess in England, when using the 2016 to 2019 and 2021 five-year average, was 5,655 below what we would expect. This decreases to 1,481 deaths below what we would expect when the 2015 to 2019 average is used.

In Wales in April 2022, there were 113 deaths above what we would expect in a "normal" year, when considering the 2016 to 2019 and 2021 five-year average. This decreases to 67 excess deaths when the 2015 to 2019 five-year average is used. The year-to-date excess in Wales, when using the 2016 to 2019 and 2021 five-year average, was 416 deaths below what we would expect, compared with 272 deaths below when using the 2015 to 2019 average.

Figures 7 and 8 look at the excess deaths in January to April and year-to-date when using the 2015 to 2019 five-year average and the new 2016 to 2019 and 2021 five-year average, respectively.

This section is based on the date a death occurred, rather than the date of registration used in the previous sections, to monitor current mortality trends. Further information can be found in the Measuring the data section.

In England, 36,714 deaths occurred in April 2022 (and were registered by 7 May 2022). This was 3,136 fewer deaths than the five-year average (2016 to 2019, and 2021) for April (7.9% lower). In April 2022, of all deaths that occurred, 2,222 deaths (6.1%) were due to coronavirus (COVID-19); this is an 8.6% increase compared with March 2022.

In Wales, 2,617 deaths occurred in April 2022 (and were registered by 7 May 2022). This was 119 fewer deaths than the five-year average (4.3% lower). Of all deaths that occurred in April 2022, deaths due to COVID-19 accounted for 155 deaths (5.9%); this is a 23.0% increase compared with March 2022.

The first death due to COVID-19 occurred on 30 January 2020 in England and 15 March 2020 in Wales. Figures 9 and 10 show the trends in COVID-19 death occurrences from March 2020 onwards for England and Wales, respectively.

Figure 9: In England in April 2022, daily deaths due to coronavirus (COVID-19) increased since March 2022

Number of deaths occurring on each day from March 2020 to April 2022, five-year average and range, England

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 May 2022. Death occurrences will increase as more deaths are registered, particularly for later dates.

2. Figures for 2021 and 2022 (including deaths that occurred in 2020 but were registered in 2021, and deaths that occurred in 2021 but were registered in 2022) are based on provisional mortality data.

3. Figures exclude non-residents.

4. "COVID-19" includes only deaths where COVID-19 was the underlying cause.

5. This chart includes deaths from 1 March 2020. Three deaths due to COVID-19 occurred prior to this in England (one death in January 2020 and two deaths in February 2020), but are not included here.

6. For deaths occurring in 2020 and 2021, the five-year average consists of deaths occurring between 2015 to 2019, whereas for deaths occurring in 2022 the five-year average consists of deaths occurring between 2016 to 2019 and 2021.

7. The five-year average for 2022 has been provided for 2016 to 2019 and 2021, because of the impact of the COVID-19 pandemic on deaths occurring in 2020. This provides an up-to-date comparison (rather than 2015 to 2019) of the number of deaths expected per day in a usual (non-coronavirus pandemic) year.

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Figure 10: In Wales in April 2022, daily deaths due to coronavirus (COVID-19) increased since March 2022

Number of deaths occurring on each day from March 2020 to April 2022, five-year average and range, Wales

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 May 2022. Death occurrences will increase as more deaths are registered, particularly for later dates.

2. Figures for 2021 and 2022 (including deaths that occurred in 2020 but were registered in 2021) are based on provisional mortality data.

3. Figures exclude non-residents.

4. “COVID-19 deaths” include only deaths where COVID-19 was the underlying cause.

5. For deaths occurring in 2020 and 2021 the five-year average consists of deaths occurring between 2015 to 2019, whereas for deaths occurring in 2022 the five-year average consists of deaths occurring between 2016 to 2019 and 2021.

6. The five-year average for 2022 has been provided for 2016 to 2019 and 2021, because of the impact of the COVID-19 pandemic on deaths occurring in 2020. This provides an up-to-date comparison (rather than 2015 to 2019) of the number of deaths expected per day in a usual (non-coronavirus pandemic) year.

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It is important to note that the number of death occurrences is incomplete because it is likely that more deaths need to be registered. Therefore, comparisons should be treated with caution.

In particular, instances where the number of death occurrences on each day in April was below the range of the last five years are likely to be a result of when the data extract was created. Specifically, deaths that occurred towards the end of the month may not have been registered by the time the data extract was created. We would therefore expect the number of death occurrences to be higher in future releases.

Data on pre-existing conditions of people who died due to coronavirus (COVID-19) in England and Wales for 2020 and 2021 can be found in the accompanying dataset. Quarter 1 (Jan to Mar) 2022 analysis is available in the March 2022 edition of this bulletin. Analysis of Quarter 2 (Apr to Jun) 2022 will be published in the June 2022 edition of this bulletin.

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. In this bulletin, we have adjusted the monthly ASMRs to allow for comparisons with annual rates. For more information see the Measuring the data section.

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 on coronavirus (COVID-19) disease 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 not part of the causal sequence.

More information on the pre-existing conditions methodology is available in our accompanying dataset.

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.

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. More information is available on our uncertainty pages.

This bulletin provides timely surveillance of mortality in England and Wales, based on the best available provisional data, including all-cause mortality and coronavirus (COVID-19) deaths.

Analysis contains deaths registered in April 2022 by age and sex, and also includes deaths that occurred in April 2022 by date of death. Non-residents of England and Wales are excluded. In April 2022, there were 81 deaths of non-residents that were registered in England and Wales.

Data sources

This bulletin is based primarily on death registrations. Analysis by month of death registration is consistent with the weekly death registrations release and allows for a more timely analysis than would be possible using death occurrences. There is a section on death occurrences for surveillance of recent mortality trends. Death occurrences show the number of deaths that occurred within a calendar period and give a better indication of exactly when deaths were at their highest. This allows mortality to be related to other factors such as weather patterns.

A provisional extract of death registrations and death occurrences data is taken on the first working day after the eighth of the month, to allow time for deaths to be registered. For more detail on the data sources used, see our methodology article.

Definition of COVID-19 deaths

We use the term "due to COVID-19" when referring only to deaths with an underlying cause of death of COVID-19. When considering all of the deaths that had COVID-19 mentioned anywhere on the death certificate, whether as an underlying cause or not, we use the term "involving COVID-19". The International Classification of Diseases (ICD-10) codes used to define COVID-19 are:

• U07.1: COVID-19, virus identified

• U07.2: COVID-19, virus not identified

• U09.9: post-COVID condition, unspecified (this cannot be assigned to the underlying cause of death so is not included in the "deaths due to COVID-19" definition)

• U10.9: multisystem inflammatory syndrome associated with COVID-19, unspecified

Our definition of COVID-19 (regardless of whether it was the underlying cause or mentioned elsewhere on the death certificate) includes some cases where the certifying doctor suspected the death involved COVID-19 but was not certain (U07.2). For example, a doctor may have clinically diagnosed COVID-19 based on symptoms but this diagnosis may not have been confirmed with a test, so they may write "suspected COVID-19" on the death certificate. Of the 152,447 deaths due to COVID-19, 4,154 (2.7%) were classified as "suspected" COVID-19. Including all 176,446 deaths involving COVID-19, "suspected" COVID-19 was recorded on 4,787 deaths (2.7%) of all deaths involving COVID-19 in England and Wales (excluding non-residents). For more information on the ICD-10 definition of COVID-19, see our methodology article.

Monthly mortality rates

To calculate monthly mortality rates that are comparable with annual rates, adjustments must be made to annual population estimates to account for the time period covered. Our methodology article provides more detail on how this is calculated.

Acknowledgement

We would like to thank Rhys Owen-Williams, Craig Arnold, Joshua Davidson-Morgan and Paul Brown for their valued contribution to this bulletin.

Provisional data are used

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 for 2021 and 2022 are provisional, they are subject to change.

Data coverage, timeliness, and registration delays

Mortality data give complete population coverage. They ensure the estimates are of high precision and representative of the underlying population at risk. However, because of registration delays, monthly death occurrence data are always somewhat incomplete. This is especially true for deaths that occurred towards the end of the month.

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