Place and Underlying Cause of Death During the COVID-19 Pandemic: Retrospective Cohort Study of 3.5 Million Deaths in England and Wales, 2014 to 2020

Abstract

Objective: To describe the place and cause of death during the coronavirus disease 2019 (COVID-19) pandemic to assess its impact on excess mortality.

Methods: This national death registry included all adult (aged ≥18 years) deaths in England and Wales between January 1, 2014, and June 30, 2020. Daily deaths during the COVID-19 pandemic were compared against the expected daily deaths, estimated with use of the Farrington surveillance algorithm for daily historical data between 2014 and 2020 by place and cause of death.

Results: Between March 2 and June 30, 2020, there was an excess mortality of 57,860 (a proportional increase of 35%) compared with the expected deaths, of which 50,603 (87%) were COVID-19 related. At home, only 14% (2267) of the 16,190 excess deaths were related to COVID-19, with 5963 deaths due to cancer and 2485 deaths due to cardiac disease, few of which involved COVID-19. In care homes or hospices, 61% (15,623) of the 25,611 excess deaths were related to COVID-19, 5539 of which were due to respiratory disease, and most of these (4315 deaths) involved COVID-19. In the hospital, there were 16,174 fewer deaths than expected that did not involve COVID-19, with 4088 fewer deaths due to cancer and 1398 fewer deaths due to cardiac disease than expected.

Conclusion: The COVID-19 pandemic has resulted in a large excess of deaths in care homes that were poorly characterized and likely to be the result of undiagnosed COVID-19. There was a smaller but important and ongoing excess in deaths at home, particularly from cancer and cardiac disease, suggesting public avoidance of hospital care for non-COVID-19 conditions.

Figure 1

Times series of daily deaths in England and Wales, 2014 to 2020. The number of daily deaths is presented using a 7-day simple moving average (indicating the mean number of daily deaths for that day and the preceding 6 days). The green line represents daily deaths in all places, the yellow line represents daily deaths in the hospital, the brown line represents daily deaths at care homes and hospices, and the blue line represents daily deaths at home.

Figure 2

Time series of daily deaths according to COVID-19 by place of death. The number of daily deaths is presented using a 7-day simple moving average (indicating the mean number of daily deaths for that day and the preceding 6 days) from February 1, 2020, up to and including June 30, 2020, adjusted for seasonality. The number of non–COVID-19 excess deaths each day from February 1, 2020, was subtracted from the expected daily death estimated by the Farrington surveillance algorithm in the same period. The brown line is a zero historical baseline. The green line represents daily COVID-19 deaths from March 2 to June 30, 2020; the blue line represents daily non–COVID-19 deaths from March 2 to June 30, 2020.

Figure 3

Time series of daily deaths according to COVID-19 by underlying cause of death. The number of daily deaths is presented using a 7-day simple moving average (indicating the mean number of daily deaths for that day and the preceding 6 days) from February 1, 2020, up to and including June 30, 2020, adjusted for seasonality. The number of non–COVID-19 excess deaths each day from February 1, 2020, was subtracted from the expected daily death estimated by the Farrington surveillance algorithm in the same period. The brown line is a zero historical baseline. The green line represents daily COVID-19 deaths from March 2 to June 30, 2020; the blue line represents daily non–COVID-19 deaths from March 2 to June 30, 2020.