30% of Recent UK ‘COVID Deaths’ Were Not Caused by COVID

Not an underlying cause of death according to the death certificate

World Health Organisation guidelines state that “COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease, or is assumed to have caused, or contributed to death, i.e. COVID-19 is the underlying cause of death”. Such an example would be someone who has developed pneumonia as a result of COVID-19, dies from acute respiratory distress. Alternatively, COVID-19 may be present on the death certificate as a significant condition contributing to death but not the underlying cause. These guidelines are clear that in such cases these deaths “are not deaths due to COVID-19 and should not be certified as such”:

We set out to determine how many COVID-19 deaths where COVID-19 is the underlying cause and when  COVID-19 is not considered as the underlying cause using Public Health England (PHE) weekly reports on excess mortality (published since the week ending 3 July 2020).

This allowed us to address the question of whether COVID-19 is the underlying cause of death when it appears on the death certificate.

What did we find

While we found that roughly one in thirteen (7.8%) deaths with COVID-19 on the death certificate did not have the disease as the underlying cause of death, this proportion has risen substantially to 29% (nearly a third) for the last eight weeks of reporting.

What we did

Deaths are classified by the underlying cause of death (“the disease or injury which initiated the train of morbid events leading directly to death”) according to major groupings such as ischaemic heart disease and cancer, and a final catch-all “All Other Causes (Excl. COVID-19)”. We use this information to infer information about deaths where COVID-19 is certified as the underlying cause of death.

First, we use information from the most recent at the time of writing excess mortality report, based on deaths until 28 August to infer the total number of deaths where COVID-19 was stated as the underlying cause of death:

  • The sum of the total deaths in Table 7 of the report shows 218,143  deaths without COVID-19 certified as the underlying cause of death.
  • Figure 2 of the report shows 263,826 registered deaths in this period.

The difference between these two numbers gives the total number of deaths where COVID-19 is certified as the underlying cause: 45,683.

  • Figure 2 reports 49,560 deaths where COVID-19 is mentioned on the death certificate.

This implies that there were 3,877 (7.8%) death certificates, where COVID-19 was not the underlying cause of death (49560-45683).

Second, we use similar calculations for every mortality report published to date to obtain the total number and proportion of death certificates that featured COVID-19, not as the underlying cause of death. These numbers are tabulated by week below:

Mortality report as of COVID-19 death certificate mentions COVID-19 as the underlying cause COVID-19 not as the underlying cause % not as the underlying cause
28/08/2020 108 78 30 27.8%
21/08/2020 120 78 42 35.0%
14/08/2020 131 91 40 30.5%
07/08/2020 142 99 43 30.3%
31/07/2020 199 140 59 29.6%
24/07/2020 227 158 69 30.4%
17/07/2020 299 225 74 24.7%
10/07/2020 391 283 108 27.6%
Total since first publication 1617 1152 465 28.8%

While the total proportion of COVID-19 death certificates not featuring COVID-19 as the underlying cause of death is only 7.8%, this figure has stood at almost 30% (465 of 1,617 deaths in total) over the time period that PHE have published the weekly mortality report.

This is broadly in line with figures published by the National Records of Scotland indicating that COVID-19 was the underlying cause in 94.6% of death certificates with any such mention until week 21, but only 76.3% from week 22 to week 32.

While death certification is rightly regarded as a gold standard for the ascertainment of cause of death, it is important to be able to distinguish between deaths where COVID-19 was a contributory cause from those where COVID-19 was the underlying cause of death. It appears that, over the course of the epidemic, a change to the respective composition of deaths in this regard has taken place.

The distinction between the underlying cause of death and any other mention on the death certificate will be increasingly important as we enter the autumn and winter months, where increases in respiratory illness are observed annually. This is particularly so since the ONS’s weekly release of data includes a breakdown of deaths featuring COVID-19 according to whether it appeared in any mention on the death certificate, and of a broad classification of ICD-10 codes only according to whether any featured as the underlying cause of death.

Source: Centre for Evidence-Based Medicine, University of Oxford 

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