Monthly mortality analysis, England and Wales: November 2021

• In November 2021, there were 48,180 deaths registered in England, 6,511 deaths (15.6%) more than the November five-year average (2015 to 2019); there were 3,344 deaths registered in Wales, 557 deaths (20.0%) more than the November average.
• The leading cause of death in November 2021 was dementia and Alzheimer's disease in England (accounting for 11.8% of all deaths) and ischaemic heart diseases in Wales (accounting for 10.7% of all deaths).
• Coronavirus (COVID-19) was the third leading cause of death in November 2021, in both England (accounting for 6.6% of all deaths) and Wales (accounting for 9.0% of all deaths).
• Taking into account the population size and age structure, the age-standardised mortality rate (ASMR) for deaths due to COVID-19 in England increased significantly to 69.3 deaths per 100,000 people; the ASMR for deaths due to COVID-19 in Wales was 106.4 deaths per 100,000 people, which was higher than October 2021 but was not statistically significant.
• Yorkshire and The Humber remained the English region with the highest ASMR for deaths due to COVID-19 in November 2021 (91.9 deaths per 100,000 people).

Based on provisional data, there were 48,180 deaths registered in England in November 2021. This was 278 more deaths than in November 2020 and 6,511 deaths more than the five-year average (2015 to 2019) (15.6% higher).

The five-year average has been provided for 2015 to 2019 (rather than 2016 to 2020) because of the impact of the coronavirus (COVID-19) pandemic on deaths registered in 2020. The average for 2015 to 2019 provides a comparison of the number of deaths expected in a usual (non-pandemic) year.

In Wales, the provisional number of deaths registered in November 2021 was 3,344. This was 17 fewer deaths than in November 2020 and 557 more deaths than the five-year average for November (20.0% higher).

Age-standardised mortality rates (ASMRs) are used for comparisons over time rather than numbers of deaths, as ASMRs account for changes to the population size and age structure. In England, mortality rates for the month of November generally decreased over time from 1,227.9 per 100,000 people in November 2001 to 904.0 deaths per 100,000 people in November 2014. This was followed by statistically significant increases in November 2015 and 2016 (935.6 deaths per 100,000 and 1,031.7 per 100,000 respectively). The ASMR generally decreased from 2017 to 2019 (947.7 deaths per 100,000 people) before significantly increasing in November 2020 (1,060.4 deaths per 100,000 people). In November 2021, the ASMR decreased compared with the previous year (1,042.7 deaths per 100,000 people) but this was not a significant decrease. This pattern in ASMRs over time was seen in both males and females (Figure 1).

In Wales, mortality rates for November have generally decreased over time. The ASMR decreased from 1,306.9 per 100,000 people in November 2003 to a low of 942.5 deaths per 100,000 people in November 2014. The ASMR then increased significantly in 2015 and 2016 before generally decreasing from 2017 to 2019. The ASMR statistically significantly increased to 1,214.2 per 100,000 people in November 2020. In November 2021, the mortality rate decreased to 1,184.3 deaths per 100,000 people; however, this was not significantly lower than the previous year.

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.

Since March 2020 (when the first deaths involving coronavirus (COVID-19) were registered in England and Wales), where COVID-19 was mentioned on the death certificate it was the underlying cause of death in most cases (88.6% in England, 87.2% in Wales). For more information on our definition of COVID-19 deaths, see Section 10: Measuring the data.

Of the 48,180 deaths registered in November 2021 in England, 6.6% (3,185 deaths) were due to COVID-19, a larger proportion than in October 2021 (5.6%). Including all deaths involving COVID-19 (3,752 deaths), this percentage increases to 7.8% of all deaths in England in November 2021.

In Wales, 9.0% of the 3,344 deaths registered in November 2021 were due to COVID-19 (302 deaths), a smaller proportion than in October 2021 (9.5%). Including all deaths involving COVID-19 (360 deaths), this percentage increases to 10.8% 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 November 2021 showed statistically significant increases compared with October 2021. The ASMR for deaths due to COVID-19 increased to 69.3 deaths per 100,000 people in November 2021 (compared with 50.8 in October 2021). In Wales, the ASMR increased to 106.4 deaths per 100,000 people in November 2021 (compared with 97.6 in October 2021), but this increase was not statistically significant. November 2021 is the third consecutive month where the ASMR for deaths due to COVID-19 in Wales was higher than in England.

In England, the ASMR for deaths due to COVID-19 significantly increased in November 2021 for both males (94.2 deaths per 100,000 males) and females (49.6 deaths per 100,000 females), compared with October 2021.

In November 2021, the ASMRs for deaths due to COVID-19 in Wales increased compared with October 2021 in males (147.0 deaths per 100,000 males) but this was not statistically significant and remained the same for females (73.7 deaths per 100,000 females) as in October 2021.

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

Figures 3 and 4 show the 10 most common underlying causes of death (based on the leading causes of death groupings), registered in November 2021 for England and Wales, compared with the five-year average for November (2015 to 2019).

In England, dementia and Alzheimer's disease continued to be the leading cause of death in November 2021, at 122.3 deaths per 100,000 people (5,701 deaths). In Wales, ischaemic heart diseases were the leading cause of death, at 126.0 deaths per 100,000 people (357 deaths).

In England, coronavirus (COVID-19) was the third leading cause of death in November 2021 (3,185 deaths), remaining consistent with the previous two months (September and October 2021). In Wales, COVID-19 was the third leading cause of death in November 2021 (302 deaths), also remaining consistent with the previous two months.

In England in November 2021, 3 of the 10 leading causes of death were statistically significantly lower than the five-year average (2015 to 2019), and 5 of the 10 leading causes had no significant difference to the five-year average. As seen in previous months, the mortality rate for deaths with an underlying cause of influenza and pneumonia was lower in November 2021 than the five-year average for November (21.6% lower). This is likely in part to be because of people continuing to follow coronavirus guidance, such as social distancing, reducing the spread of infections such as flu.

Similar to recent months, in November 2021, symptoms, signs and ill-defined conditions were significantly higher than the five-year average in England. In November 2021, the mortality rate for symptoms, signs and ill-defined conditions was 23.8% higher than the five-average for November. This leading cause group includes mostly deaths with a code for "old age" but is also used for causes such as "frailty".

In Wales in November 2021, mortality rates for 7 of the 10 leading causes were similar to the five-year average. As seen in England, the November 2021 mortality rate for influenza and pneumonia was significantly lower than the five-year average for November (29.8% lower).

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

In the first 11 months (January to November) of 2021, the leading cause of death in England was COVID-19 (119.2 deaths per 100,000 population). In Wales, the leading cause of death was ischaemic heart diseases (114.5 deaths per 100,000 people), followed by COVID-19 (110.9 deaths per 100,000 people).

In England, the year-to-date COVID-19 mortality rate was significantly higher than the next leading cause of death (dementia and Alzheimer's disease). In Wales, in January to November 2021, the number of deaths due to ischaemic heart diseases and COVID-19 were similar (3,577 and 3,475 deaths respectively). There was no significant difference in mortality rates between the two causes.

More information on the 2021 year-to-date leading causes of death is available in Tables 11a and 11b of the accompanying dataset. More in-depth analysis of leading causes of death is available in our annual publication based on finalised mortality data.

There were 499,938 deaths registered in England and 32,806 in Wales during the first 11 months (January to November) of 2021.

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 November of each year from 2001 to 2021 (Figure 5). For England, the year-to-date ASMR for 2021 was 980.1 deaths per 100,000 people, which was statistically significantly lower than the same period in 2020 (1,033.2 deaths per 100,000 people). However, when compared with the same period in 2019 (915.4 deaths per 100,000 people), the 2021 year-to-date mortality rate was significantly higher.

For Wales, the year-to-date ASMR for 2021 significantly decreased to 1,053.4 deaths per 100,000 people when compared with the same period in 2020 (1,089.5 deaths per 100,000 people). But, as with England, January to November 2021 was significantly higher than the same period in 2019 (992.7 deaths per 100,000 people).

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 Section 10: Measuring the data.

In England, 40,772 deaths occurred in November 2021 (and were registered by 7 December 2021). This was 741 fewer deaths than the five-year average (2015 to 2019) for November (1.8% lower). Of all deaths that occurred, 6.7% were due to coronavirus (COVID-19) (2,734 deaths).

In Wales, 2,857 deaths occurred in November 2021 (and were registered by 7 December 2021), which was 71 more deaths than the five-year average (2.5% higher). COVID-19 was the underlying cause of death in 8.4% of all deaths that occurred (240 deaths).

In England, the first death due to COVID-19 occurred on 30 January 2020, whereas in Wales the first death due to COVID-19 occurred on the 15 March 2020. Figures 6 and 7 show the trends in COVID-19 death occurrences from March 2020 onwards, for England and Wales respectively.

Figure 6: In England in November 2021, daily deaths due to COVID-19 remained low

Number of deaths occurring on each day from March 2020 to November 2021, five-year average and range, England

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 December. Death occurrences will increase as more deaths are registered, particularly for later dates.
2. Figures for 2021 (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. 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.

Download the data

Figure 7: In Wales in November 2021, daily deaths due to COVID-19 remained similar to October 2021

Number of deaths occurring on each day from March 2020 and November 2021, five-year average and range, Wales

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 December. Death occurrences will increase as more deaths are registered, particularly for later dates.
2. Figures for 2021 (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.

Download the data

It is important to note that the number of death occurrences is incomplete as 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 November 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.

In this section we use the multiple health conditions that can be recorded on a death certificate to identify deaths where there were pre-existing health conditions that contributed to the cause of death where death was due to coronavirus (COVID-19). Health conditions are recorded on the death certificate only if the certifying doctor or coroner believed they made some contribution to the death, direct or indirect. The death certificate does not include all health conditions from which the deceased might have suffered if they were not considered relevant. However, the fact that a pre-existing condition was recorded does not suggest that the deceased was likely to have died from that condition in the absence of the COVID-19 infection.

This section analyses data from Quarter 3 (July to Sept) of 2021, whereas the rest of the bulletin analyses data up to November.

This analysis of pre-existing conditions covers England and Wales as a whole only because of the small number of deaths due to COVID-19 in Wales in Quarter 3 2021 (358 deaths due to COVID-19).

Overall patterns of pre-existing conditions for COVID-19 deaths in Quarter 3 were similar to Quarter 2 (Apr to June) of 2021. Diabetes remained the most common pre-existing condition of deaths due to COVID-19 (22.5%), followed by chronic lower respiratory diseases which were second most common at 19.4% (up from third most common in Quarter 2 at 15.3%).

In Quarter 3, the total number of deaths due to COVID-19 in England and Wales increased to 6,572 deaths (from 1,838 deaths in Quarter 2). However, the proportion of COVID-19 deaths for each age group remained similar. Those aged between 0 and 64 years accounted for 24.2% of all COVID-19 deaths in Quarter 3 (compared with 26.3% in Quarter 2) and those aged 65 years and over accounted for 75.8% of all COVID-19 deaths (compared with 73.7% in Quarter 2). Overall, the proportion of COVID-19 deaths with no pre-existing conditions remained similar in Quarter 3 (17.4%) to Quarter 2 (18.8%) (see Table 2 in the dataset). Likewise, the average number of different pre-existing conditions per COVID-19 death remained similar between these two periods (1.9 and 2.0 pre-existing conditions on average in Quarter 3 and Quarter 2 respectively).

In Quarter 3, diabetes remained the most common pre-existing condition for deaths due to COVID-19 occurring in hospitals (24.8%, down slightly from 25.9% in Quarter 2). Dementia and Alzheimer's disease also remained the most common pre-existing condition for deaths occurring in care homes (46.3%), the largest increase in comparison with Quarter 2 (25.3%).

The proportion of COVID-19 deaths occurring in private homes with diabetes as a pre-existing condition decreased to 14.6% (from 19.2% in Quarter 2). Despite this, diabetes returned to being the most common pre-existing condition for COVID-19 deaths in private homes, after dropping to second most common in Quarter 2. Chronic lower respiratory diseases were the second most common pre-existing condition for COVID-19 deaths in private homes at 13.7% (from 11.6% in Quarter 2 where it was fourth most common). The proportion of deaths due to COVID-19 in private homes with hypertensive diseases as a pre-existing condition, dropped from most common in Quarter 2 (20.8%) to fifth most common in Quarter 3 (9.1%).

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 Section 10: Measuring the data.

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 World Health Organization (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 information on the pre-existing conditions methodology is available in the 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 November 2021 by age and sex, and also includes deaths that occurred in November 2021 by date of death. Non-residents of England and Wales are excluded. In November 2021, there were 78 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 taking into account 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 137,918 deaths due to COVID-19, 4,146 (3.0%) were classified as "suspected" COVID-19. Including all 155,753 deaths involving COVID-19, "suspected" COVID-19 was recorded on 3.1% (4,770 deaths) of all deaths involving COVID-19 in England and Wales. For more information on the ICD-10 definition of COVID-19, see Section 8 of the 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. Section 2 of the methodology article provides more detail on how this is calculated.

Acknowledgement

We would like to thank Rhys Owen-Williams, Charlee Humphries, and Ben Aspey 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 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 are 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 the Mortality statistics in England and Wales QMI and User guide to mortality statistics.