Deaths involving COVID-19 in the care sector, England and Wales: deaths registered between week ending 20 March 2020 and week ending 21 January 2022

• Since the beginning of the coronavirus (COVID-19) pandemic, there have been 274,063 deaths of care home residents (wherever the death occurred) registered in England and Wales; of these, 45,632 involved COVID-19 accounting for 16.7% of all deaths of care home residents.
• Total deaths of care home residents in England increased by 16.5% between the first and second waves of the pandemic (85,305 and 99,380 deaths respectively) and decreased by 23.9% between the second and third waves (75,664 deaths); the proportion of deaths involving COVID-19 was highest in the first wave (23.2%) and lowest in the third wave (3.6%).
• Total deaths of care home residents in Wales increased by 30.0% between the first and second waves (4,196 and 5,454 deaths respectively) and decreased by 27.0% between the second and third waves (3,980 deaths); the proportion of deaths involving COVID-19 was highest in the second wave (23.8%) and lowest in the third wave (4.9%).
• In the first wave there were more total deaths of care home residents compared with the five-year average (26,035 and 1,046 excess deaths for England and Wales respectively), but deaths fell below the five-year average in the second and third waves.
• In both England and Wales, Dementia and Alzheimer disease was the leading cause of death across all waves, except for male care home residents in the first wave in England where COVID-19 was the leading cause of death (24.8%); COVID-19 was not one of the top three leading causes of death for care home residents in the third wave.
• In both England and Wales, the mean number of pre-existing conditions did not change substantially over the three waves, with Dementia and Alzheimer disease being the most common in both male and female care home residents.

For the purposes of this release, using death registration data, the waves (see Glossary) of the coronavirus (COVID-19) pandemic have been defined as:

• first wave: deaths registered from 14 March to 11 September 2020
• second wave: deaths registered from 12 September 2020 to 11 June 2021
• third wave: deaths registered from 12 June 2021 to 21 January 2022

The first, second and third waves constitute 26, 39, and 32 weeks respectively. Therefore, we have calculated proportions to allow comparisons across waves.

"Deaths of care home residents" refers to both (a) deaths occurring in a care home to residents, and (b) deaths where the deceased resided in a care home but died elsewhere. The figures should not be confused with "deaths in care homes" reported in other publications, which refers only to category (a).

The term "due to COVID-19" refers to deaths with an underlying cause of death as COVID-19. The term "involving COVID-19" refers to deaths that had COVID-19 mentioned anywhere on the death certificate.

Between the week ending 20 March 2020 and the week ending 21 January 2022, 274,063 deaths of care home residents were registered in England and Wales. Of these, 45,632 involved COVID-19, accounting for 16.7% of all deaths of care home residents.

Updated data on place of death, geography and personal characteristics (age and sex) are available in the accompanying dataset.

Of the 260,349 deaths registered in England across all waves of the coronavirus (COVID-19) pandemic, 32.8% of deaths were registered during the first wave (85,305 deaths), 38.2% were registered during the second wave (99,380 deaths), and 29.1% were registered during the third wave (75,664 deaths).

Across all waves, there were 43,256 mentions of “novel coronavirus” (COVID-19) anywhere on the death certificate, accounting for 16.6% of all care home resident deaths in England. The sharpest rise in deaths involving COVID-19 was registered in the first wave (Figure 1), which was the wave that had the highest proportion of deaths involving COVID-19 (19,783 deaths, 23.2%). In the second wave, 20.9% of care home resident deaths involved COVID-19 (20,766 deaths) compared with a steep drop in the third wave, with 3.6% of all deaths involving COVID-19 (2,707 deaths).

There is evidence of a period of mortality displacement (see Glossary) following the peak of the second wave in England (week ending 29 January 2021, 4,599 deaths), as the weekly total deaths from the week ending 19 February 2021 to the week ending 16 July 2021 are all below the five-year average (Figure 1). Following this period of mortality displacement, deaths more closely align to the weekly five-year average during the third wave.

Overall, total deaths of care home residents in England were 8.4% higher than the five-year average across all waves (20,268 excess deaths; see Glossary). Total deaths were 43.9% higher than the five-year average for the first wave (26,035 excess deaths), 3.1% lower for the second wave (3,200 deaths below average) and 3.3% lower for the third wave (2,567 deaths below average).

Of the 13,630 deaths registered in Wales across all waves of the coronavirus (COVID-19) pandemic, 30.8% of deaths were registered during the first wave (4,196 deaths), 40.0% were registered during the second wave (5,454 deaths), and 29.2% were registered during the third wave (3,980 deaths).

Across all waves, there were 2,367 mentions of “novel coronavirus” (COVID-19) anywhere on the death certificate, accounting for 17.4% of all care home resident deaths in Wales. While the sharpest rise in deaths involving COVID-19 were registered in the first wave (20.9%, 876 deaths), there was a higher proportion of deaths involving COVID-19 in the second wave (23.8%, 1,297 deaths). The third wave had the lowest proportion (4.9%) of deaths involving COVID-19 (194 deaths).

Overall, total deaths of care home residents in Wales were 5.9% higher than the five-year average across all waves (756 excess deaths; see Glossary). Total deaths were 33.2% higher than the five-year average for the first wave (1,046 excess deaths), 1.8% lower for the second wave (100 deaths below average) and 4.6% lower for the third wave (190 deaths below average).

Both England and Wales experienced excess deaths in care home residents in the first wave of the coronavirus (COVID-19) pandemic, but not in the second or third waves (Figures 2 and 4). There are several possible reasons for this, including:

• vulnerability of the care home resident population because of their age, health and susceptibility to viruses
• increased care support packages and introduction of the local COVID-19 alert levels system later during the pandemic
• “mortality displacement” where the higher number of deaths registered in the first wave and peak of the second wave could be contributing to the lower deaths registered later in the second wave and the third wave
• lower levels of care home occupancy in the second wave; possible reasons for this could include the care home population not yet having returned to normal after a greater number of deaths earlier in the year, care homes limiting capacity because of social distancing measures, and a delay in individuals moving into care homes because of perceived risk of infection
• availability of COVID-19 vaccinations, including boosters in the third wave, for which care home residents were a prioritised group

The Office for National Statistics’ leading causes of death groupings are based on a list developed by the World Health Organization (WHO). This categorises causes of death using the International Classification of Diseases, 10th edition (ICD-10) into groups that are epidemiologically more meaningful than single ICD-10 codes, for the purpose of comparing the most common causes of death in the population.

Coronavirus (COVID-19) was the leading cause of death in male care home residents in England in the first wave of the coronavirus pandemic accounting for 24.8% of deaths. This dropped to the second leading cause in the second wave (19.2% of deaths) and the eighth leading cause in the third wave (3.3% of deaths).

Dementia and Alzheimer disease remained the leading cause of death for female care home residents in all three waves accounting for 32.6%, 31.9% and 37.3% of deaths respectively. COVID-19 was the second leading cause of death in the first and second waves for female care home residents (19.6% and 17.9% of deaths respectively) and this dropped to the sixth leading cause in the third wave (2.5% of deaths).

In England, the three highest leading causes of death in the third wave are aligned with pre-coronavirus pandemic conditions for both male and female care home residents.

In Wales, Dementia and Alzheimer disease remained the leading cause of death across all three waves for both male (25.2%, 24.3%, and 32.1% respectively) and female care home residents (34.2%, 32.7% and 39.7% respectively).

COVID-19 was the second leading cause of death in both male and female care home residents in the first wave (23.1% and 17.0% respectively) and the second wave (23.7% and 19.6% respectively). In the third wave, COVID-19 dropped to the fourth leading cause of death in both male (5.1%) and female (3.7%) care home residents.

The full list of leading causes broken down by sex, for both England and Wales, are included in the accompanying dataset.

We analysed pre-existing conditions (see Glossary) where coronavirus (COVID-19) was the underlying cause of death among care home residents. A death record can list up to 15 pre-existing conditions so the total number of pre-existing conditions may be higher than the total for deaths. For more detail, please see Measuring pre-existing health conditions in death certification - deaths involving COVID-19. For this analysis data for pre-existing conditions is based on deaths registered between 14 March 2020 and 31 December 2021 as pre-existing condition data for 2022 have not been analysed.

In England, of the care home resident deaths where COVID-19 was the underlying cause up until week ending 31 December 2021 (38,296 deaths), 86.6% (33,161 care home residents) had at least one pre-existing condition (86.7% first wave, 86.6% second wave, and 85.1% third wave). The mean number of pre-existing conditions of care home residents was 1.7 in the first and second waves, and 1.8 in the third wave. The three most common pre-existing conditions did not change across the waves for male or female care home residents.

In Wales, of the care home resident deaths where COVID-19 was the underlying cause up until week ending 31 December 2021 (2,077 deaths), 81.3% (1,688 care home residents) had at least one pre-existing condition (78.1% first wave, 83.8% second wave, and 78.2% third wave). The mean number of pre-existing conditions of care home residents was 1.4 in the first and second waves, and 1.5 in the third wave.

The breakdowns by sex and wave for the ten most common pre-existing conditions in deaths due to COVID-19 are available in the accompanying dataset.

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 death certificates mentioning the virus as a contributory factor.

Coronavirus (COVID-19)

COVID-19 refers to the "coronavirus disease 2019" that can affect the lungs and airways. It is caused by a type of coronavirus. Further information is available from the WHO.

Deaths due to COVID-19

The term "due to COVID-19" refers to deaths with an underlying cause of death as COVID-19 Deaths involving COVID-19.

Deaths involving COVID-19

The term "involving COVID-19" refers to deaths that had COVID-19 mentioned anywhere on the death certificate.

Excess deaths

Excess deaths are those deaths that are above the five-year average levels. For example, if on average 100 people died on this day over the past five years, but 120 died on the same day this year, this would mean there are 20 excess deaths. Where we have calculated excess deaths for wave two, the week 52 five-year average is used to compare against week 53 2020 deaths.

Mortality displacement

This is an effect where higher numbers of deaths in earlier weeks could be contributing to the lower levels observed in recent weeks, because some people who may have otherwise died in the later weeks could have died a few weeks earlier.

Pre-existing condition

A pre-existing condition is defined as any condition that either preceded the disease of interest in the sequence of events leading to death or was a contributory factor in the death but was not part of the causal sequence.

Where only COVID-19 was recorded on the death certificate, or only COVID-19 and subsequent conditions caused by COVID-19 were recorded, we refer to these deaths as having "No pre-existing conditions".

Waves

The first care home resident death involving COVID-19 was registered on 17 March 2020, therefore the week ending 20 March 2020 will form the beginning of the first wave in this article, ending on 11 September 2020. The second wave is from 12 September 2020 up to 11 June 2021. The third wave is from 12 June 2021 up to the most recent data available at the time of analysis (week ending 21 January 2022). Waves are defined using infections data from the Covid Infection Survey.

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. The counts of deaths from specific conditions are updated with each weekly deaths publication as the coding of the underlying cause is not always complete at the time of production. 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.

The information used to produce these statistics is based on details collected when certified deaths are registered with the local registration office. Our statistics are based on what the doctor writes on the death certificate. Doctors use their professional knowledge and judgement to decide what caused or contributed to the death. Their opinion does not have to be based on test results. 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.

Figures on deaths published by the Office for National Statistics (ONS) differ from those produced by the Department of Health and Social Care (DHSC) and the UK's public health agencies. Our blog  Counting deaths involving COVID-19 helps to explain the differences.

In England and Wales, deaths should be registered within five days of the death occurring, but there are some situations that result in the registration of the death being delayed. For example, when a death needs to be investigated by a coroner. More information on this issue can be found in our impact of registration delays release.

There have been fluctuations in occupancy rates in care homes because of the coronavirus (COVID-19) pandemic, therefore we have been unable to accurately estimate a care home resident population during this time period; because of this, mortality rates have not been calculated for this publication.

Final death registrations have been used for 2020 data up to week 52 (week ending 25 December 2020). From week 53 2020 (week ending 1 January 2021), including all of 2021 and 2022, data are provisional. As the data are provisional, they are subject to change. Therefore, numbers reported in previous releases may be different to the numbers reported here.

For finalised 2020 data, we used the communal establishment file we used for our previous release. We have used the most up-to-date communal establishment file we have for 2021 and 2022 data. Therefore, there is some potential for under- and over-coverage within the figures provided.

Where we refer to the five-year average, this is based on the actual number of death registrations recorded for the corresponding time period in the years:

• 2015 to 2019; for 2020 and 2021 figures
• 2016, 2017, 2018, 2019 and 2021; for 2022 figures

The year 2020 has been excluded from the five-year average calculations because of the impact of the coronavirus pandemic on deaths registered in that year. Please see our blog Understanding excess deaths during a pandemic for further information.

There are some differences in death statistics between countries of the UK, but these are believed to have a negligible impact on comparability.

Deaths involving COVID-19, including those in the care sector, are reported for each week in our Deaths registered weekly in England and Wales, provisional release.

Our User guide to mortality statistics provides further information on data quality, legislation and procedures relating to mortality and includes a glossary of terms.