Monthly mortality analysis, England and Wales: September 2021

• In September 2021, there were 44,474 deaths registered in England, 7,215 deaths (19.4%) more than the September five-year average (2015 to 2019) and there were 2,964 deaths registered in Wales, 489 deaths (19.8%) more than the September average.

• The leading cause of death in September 2021 was dementia and Alzheimer's disease in England (accounting for 11.2% of all deaths) and ischaemic heart diseases in Wales (9.6% of all deaths).

• Coronavirus (COVID-19) was the third leading cause of death, in September 2021, in England (accounting for 6.6% of all deaths registered in September) and in Wales (accounting for 8.5% 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 (64.4 deaths per 100,000 people) increased significantly for the third consecutive month; the ASMR for deaths due to COVID-19 in Wales was 89.6 deaths per 100,000 people, significantly higher than in August 2021.

• The North East of England remained the English region with the highest ASMR for deaths due to COVID-19 in September 2021 (89.9 deaths per 100,000 people) for the second consecutive month; all English regions except the North East and London had statistically significant increases between August and September 2021.

Based on provisional data, there were 44,474 deaths registered in England in September 2021. This was 4,656 more deaths than in September 2020 and 7,215 deaths more than the five-year average (2015 to 2019) (19.4% 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 September 2021 was 2,964. This was 354 more deaths than in September 2020 and 489 more deaths than the five-year average for September (19.8% 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 September generally decreased over time from 1,157.1 per 100,000 people in September 2003 to a low of 794.0 deaths per 100,000 people in September 2018. This was followed by significant increases in ASMR in September 2019 and 2020 (840.7 and 885.5 deaths per 100,000 people respectively). In September 2021, mortality rates significantly increased compared with the previous year, to 966.2 deaths per 100,000 people. This pattern in ASMRs over time was seen in both males and females (Figure 1).

In Wales, mortality rates for September were also generally decreasing over time, but these improvements stalled from September 2012 onwards, in line with previous findings on changing trends in mortality. The ASMR decreased from 1,213.2 deaths per 100,000 people in September 2003, to a low of 867.6 deaths per 100,000 people in September 2018. This was followed by an increase in ASMR in September 2019 (897.2 deaths per 100,000) and in September 2020 (946.2 deaths per 100,000). However, these increases were not statistically significant. In September 2021, the mortality rate was 1,056.4 deaths per 100,000 people which was statistically significantly higher 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 (88.8% in England, 87.4% in Wales). For more information on our definition of COVID-19 deaths, see Section 10: Measuring the data.

Of the 44,474 deaths registered in September 2021 in England, 6.6% (2,955 deaths) were due to COVID-19, a larger proportion than in August 2021 (5.3%). Including all deaths involving COVID-19 (3,432 deaths) increases the percentage to 7.7% of all deaths in England in September 2021.

In Wales, 8.5% of the 2,964 deaths registered in September 2021 were due to COVID-19 (253 deaths), a larger proportion than in August 2021 (2.7%). Including all deaths involving COVID-19 (289 deaths) increases the percentage to 9.8% of all deaths in Wales.

In both England and Wales, the numbers of deaths due to COVID-19 increased compared with August 2021 but continued to be lower than the numbers seen in October 2020 to March 2021.

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 September 2021 showed statistically significant increases compared with August 2021. The ASMR for deaths due to COVID-19 increased to 64.4 deaths per 100,000 people in September 2021 (compared with 45.7 in August 2021). In Wales, the ASMR significantly increased to 89.6 deaths per 100,000 people in September 2021 (compared with 24.5 in August 2021). September 2021 is the first month since December 2020 where the ASMR for deaths due to COVID-19 is higher than in England.

In England, the ASMR for deaths due to COVID-19 significantly increased in September 2021 for males (85.3 deaths per 100,000 males) and females (47.9 deaths per 100,000 females) compared with August 2021.

In September 2021, the ASMRs for deaths due to COVID-19 in Wales significantly increased compared with August 2021 in both males (106.9 deaths per 100,000 males) and females (77.9 deaths per 100,000 females).

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 September 2021 for England and Wales, compared with the five-year average for September (2015 to 2019).

In England, dementia and Alzheimer's disease continued to be the leading cause of death in September 2021, with 107.3 deaths per 100,000 people (4,976 deaths). In Wales, ischaemic heart diseases were the leading cause of death, with 100.0 deaths per 100,000 people (284 deaths).

In England, coronavirus (COVID-19) was the third leading cause of death in September 2021 (2,955 deaths), remaining consistent with August 2021 (2,162 deaths). In Wales, COVID-19 was the third leading cause of death (253 deaths) in September 2021, its highest ranking since March 2021.

In England in September 2021, 2 of the 10 leading causes of death were significantly lower than the five-year average (2015 to 2019) and 4 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 September 2021 than the five-year average for September (23.9% 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 September 2021 symptoms, signs and ill-defined conditions were significantly higher than the five-year average in England. In September 2021, the mortality rate for symptoms, signs and ill-defined conditions was 30.8% higher than the five-average for September. 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 September 2021, mortality rates for 7 of the 10 leading causes were similar to the five-year average (not statistically significantly different). As seen in England, the September 2021 mortality rate for influenza and pneumonia was significantly lower than the five-year average for September (31.5% lower).

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

In the first nine months (January to September) of 2021, the leading cause of death in England was COVID-19 (132.2 deaths per 100,000 population). In Wales the leading cause of death was ischaemic heart diseases (113.2 deaths per 100,000) followed closely by COVID-19 (112.8 deaths per 100,000).

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 September 2021, the number of deaths due to ischaemic heart diseases and COVID-19 were the same (2,885 deaths each). However, due to the age structure of the deaths the age-standardised mortality rate due to ischaemic heart diseases was the higher than COVID-19. 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 408,338 deaths registered in England and 26,468 in Wales during the first nine months (January to September) 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 September of each year from 2001 to 2021 (Figure 5). For England, the year-to-date ASMR for 2021 was 981.1 deaths per 100,000 people, which was significantly lower than the same period in 2020 (1,042.1 deaths per 100,000 people). However, when compared with the same period in 2019 (909.1 deaths per 100,000 people), the 2021 year-to-date mortality rate was significantly higher.

For Wales, the year-to-date ASMR for 2021 decreased to 1,041.4 deaths per 100,000 people. This was statistically significantly lower than the same period in 2020 (1,080.2 deaths per 100,000 people). But, as with England, January to September 2021 was significantly higher than the same period in 2019 (984.4 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, 37,396 deaths occurred in September 2021 (and were registered by 7 October 2021). This was 373 more deaths than the five-year average (2015 to 2019) for September (1.0% higher). Of all deaths that occurred, 6.9% were due to coronavirus (COVID-19) (2,581 deaths).

In Wales, 2,574 deaths occurred in September 2021 (and were registered by 7 October 2021), which was 81 more deaths than the five-year average (3.2% higher). COVID-19 was the underlying cause of death in 9.9% of all deaths that occurred (255 deaths).

In England, the first death due to COVID-19 occurred on 30 January 2020 and in Wales the first death due to COVID-19 occurred on the 15 March 2020. Figure 6 shows the trend in COVID-19 death occurrences from March 2020 onwards.

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

Number of deaths occurring on each day from March 2020 to September 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 October.

2. Figures exclude non-residents.

3. "COVID-19 deaths" include only deaths where COVID-19 was the underlying cause.

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

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Figure 7: In Wales in September 2021, daily deaths due to COVID-19 remained low

Number of deaths occurring on each day from March 2020 and September 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 October.

2. Figures exclude non-residents.

3. "COVID-19 deaths" include only deaths where COVID-19 was the underlying cause.

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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 September 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 2021 can be found in the accompanying dataset. Quarterly analysis is available in the April 2021 edition and July 2021 edition of this bulletin. Analysis of Quarter 3 (July to Sept) 2021 will be published next month.

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 September 2021 by age and sex, and also includes deaths that occurred in September 2021 by date of death. Non-residents of England and Wales are excluded. In September 2021, there were 82 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 131,615 deaths due to COVID-19, 4,138 (3.1%) were classified as "suspected" COVID-19. Including all 148,327 deaths involving COVID-19, "suspected" COVID-19 was recorded on 3.2% (4,762 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 Rachel Rushton, Rhys Owen-Williams, Charlee Humphries, Fred Barton 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.