Monthly mortality analysis, England and Wales: May 2021

• In May 2021, there were 35,401 deaths registered in England, 4,252 deaths (10.7%) fewer than the May five-year average (2015 to 2019); this is the second consecutive month that deaths were below the five-year average in England since August 2020.

• In Wales in May 2021, there were 2,416 deaths registered, 271 deaths (10.1%) fewer than the May average.

• The coronavirus (COVID-19) was the 24th leading cause of death in May 2021 in England (accounting for 0.9% of all deaths registered in May) and the 31st leading cause of death in Wales (0.6% of all deaths).

• The leading cause of death in May 2021 in England was ischaemic heart diseases (accounting for 10.7% of all deaths); ischaemic heart diseases continued to be the leading cause of death in Wales in May 2021 (12.4% of all deaths).

• In May 2021, the age-standardised mortality rate (ASMR) of deaths due to COVID-19 decreased for the fourth consecutive month, to 7.1 deaths per 100,000 people in England and 5.2 deaths per 100,000 people in Wales; this was the lowest rate in England since August 2020, and the lowest rate in Wales since the start of the pandemic.

• ASMRs for deaths due to COVID-19 decreased across all regions of England between April and May 2021; London was the English region with the highest ASMR for deaths due to COVID-19 in May 2021 (11.2 deaths per 100,000 people), and the South West continued to have the lowest COVID-19 mortality rate (4.4 deaths per 100,000 people).

Based on provisional data, there were 35,401 deaths registered in England in May 2021. This was 14,021 fewer deaths than in May 2020 and 4,252 deaths fewer than the five-year average (2015 to 2019). May 2021 was the second month where deaths in England were below the five-year average (10.7% lower) since August 2020.

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 May 2021 was 2,416. This was 486 fewer deaths than in May 2020 and 271 fewer deaths than the five-year average for May (10.1% lower).

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 May had been generally decreasing since the time series began in 2001, from 1,210.7 deaths per 100,000 people in 2001, to a low of 748.6 deaths per 100,000 people in May 2021. The statistically significant decrease in ASMRs from 2001 was seen in both males and females (Figure 1).

In England, the May 2021 mortality rate (748.6 deaths per 100,000 people) was the lowest mortality rate for the month of May since our data time series began in 2001. The ASMR for May 2021 was significantly lower than every other year in this analysis.

In Wales, mortality rates for May had also been decreasing over time, from 1,271.4 deaths per 100,000 people in 2001 to a low of 837.2 deaths per 100,000 people in May 2021.

In May 2021, the mortality rate in Wales significantly decreased compared with May 2020 (1,019.5 deaths per 100,000 people) to 837.2 deaths per 100,000 people. The May 2021 mortality rate for Wales was significantly lower than the mortality rate in every year in our data time series.

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.

In May, in most cases (69.5% in England and 71.4% in Wales) where coronavirus (COVID-19) was mentioned on the death certificate, it was the underlying cause of death. For more information on our definition of COVID-19 deaths, see Section 10: Measuring the data.

Of the 35,401 deaths registered in May 2021 in England, 0.9% (333 deaths) were due to COVID-19. Including all deaths involving COVID-19 increases the percentage to 1.4% of all deaths (479 deaths) in England in May 2021.

In Wales, 0.6% of the 2,416 deaths registered in May 2021 were due to COVID-19 (15 deaths). Including all deaths involving COVID-19 increases the percentage to 0.9% of all deaths (21 deaths) in Wales.

In England and Wales, deaths due to COVID-19 continue to decrease (64.6% decrease in England, 57.1% decrease in Wales compared to April 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 and Wales decreased for the fourth consecutive month. In England, the ASMR for deaths due to COVID-19 decreased to 7.1 deaths per 100,000 people in May 2021 (compared with 20.6 in April 2021). In Wales, the ASMR for deaths due to COVID-19 decreased to 5.2 deaths per 100,000 people in May 2021 (compared with 12.6 in April 2021). For Wales, the ASMR should be treated with caution as it is based on a small number of deaths.

In May 2021, the ASMRs for deaths due to COVID-19 decreased for the fourth consecutive month for both males (9.2 per 100,000 males in England) and females (5.2 per 100,000 females in England and 7.1 per 100,000 females in Wales). More information on mortality rates by sex is available in Tables 3a and 3b of the accompanying dataset. For males in Wales, there were too few deaths due to COVID-19 for a rate to be provided.

Leading causes of death registered in May 2021

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

In both England and Wales, ischaemic heart diseases were the leading cause of death in May 2021, with 80.0 deaths per 100,000 people in England (3,780 deaths) and 103.8 deaths per 100,000 people in Wales (300 deaths). The second most common cause of death in May 2021 was dementia and Alzheimer's disease, with 77.8 deaths per 100,000 people in England (3,711 deaths) and 73.3 deaths per 100,000 people in Wales (212 deaths).

In England, coronavirus (COVID-19) was the 24th leading cause of death in May 2021 (333 deaths) and the 31st leading cause of death in Wales (15 deaths). This is compared with April 2021, where COVID-19 was the 9th leading cause of death in England (941 deaths) and 18th leading cause of death in Wales (35 deaths).

In England in May 2021, 9 of the 10 leading causes of death were significantly lower than the five-year average (2015 to 2019). In particular, the mortality rate for deaths with an underlying cause of influenza and pneumonia was 49.9% lower in May 2021 than the five-year average for May; this is likely in part because of coronavirus restrictions and guidance, such as social distancing, reducing the spread of infections such as flu.

In Wales, 3 of the 10 leading causes were significantly lower than the five-year average, with all other leading causes for May 2021 having similar mortality rates to the five-year average. Similar to England, the May 2021 mortality rate for influenza and pneumonia was 55.1% lower than the five-year average for May.

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

In the first five months (January to May) of 2021, the leading cause of death in both England and Wales was COVID-19, accounting for 19.8% of all deaths in England and 16.2% of all deaths in Wales. The year-to-date mortality rate for deaths due to COVID-19 was 210.5 deaths per 100,000 people in England and 178.4 deaths per 100,000 people in Wales.

In both countries, the year-to-date COVID-19 mortality rate was significantly higher than the next leading cause of death (dementia and Alzheimer's disease in England and ischaemic heart diseases in Wales).

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 244,144 deaths registered in England and 15,591 in Wales during the first five months (January to May) of 2021.

To gain a better idea of year-to-year differences in mortality rates, we calculated year-to-date age-standardised mortality rates (ASMR) based on deaths registered in January to May of each year from 2001 to 2021 (Figure 5). For England, the year-to-date age-standardised mortality rate for 2021 was 1,062.6 deaths per 100,000 people, which was statistically significantly lower than the same period in 2020 (1,203.5 deaths per 100,000 people). However, when compared with the same period in 2019 (976.3 deaths per 100,000 people), the 2021 year-to-date mortality rate was significantly higher.

For Wales, the year-to-date age-standardised mortality rate for 2021 was 1,110.8 deaths per 100,000 people. This was statistically significantly lower than the same period in 2020 (1,212.9 deaths per 100,000 people). But, similar to England, January to May 2021 was significantly higher than the same period in 2019 (1,066.7 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 May 2021, 33,494 deaths occurred in England (and were registered by 7 June). This was 6,058 fewer deaths than the five-year average (2015 to 2019) for May (15.3% lower). Of the 33,494 deaths that occurred, 0.7% were due to coronavirus (COVID-19) (226 deaths).

In Wales, 2,330 deaths occurred in May 2021 (and were registered by 7 June), which was 322 fewer deaths than the five-year average (12.1% lower). COVID-19 was the underlying cause of death in 0.4% of all deaths that occurred (10 deaths).

In England, the first death due to COVID-19 occurred on 30 January 2020. Figure 6 shows the trend in COVID-19 death occurrences from March 2020 onwards. The largest number of COVID-19 deaths that occurred in a single day in England was on 8 April 2020 (1,225 deaths), followed by 19 January 2021 (1,200 deaths).

Figure 6: In England, daily deaths due to COVID-19 continued to decrease in May 2021

Number of deaths occurring on each day from March 2020 to May 2021¹, five-year average and range, England

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 June. Death occurrences will increase as more deaths are registered, particularly for later dates.
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, daily deaths due to COVID-19 continued to decrease in May 2021

Number of deaths occurring on each day from March 2020 to May 2021¹, five-year average and range, Wales

Notes:

1. Figures are for deaths occurring on each day rather than deaths registered, registered up to 7 June 2021. Death occurrences will increase as more deaths are registered, particularly for later dates.
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 May 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. Detailed information on this analysis is available in the April 2021 edition of this bulletin. This analysis will be updated on a quarterly basis in the July edition.

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 Organisation (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 May 2021 by age and sex, and also includes deaths that occurred in May 2021 by date of death. Non-residents of England and Wales are excluded. In May 2021, there were 47 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 8th 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 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. For example, a doctor may have clinically diagnosed COVID-19 based on symptoms, but this diagnosis may not have been confirmed with a test. Of the 124,200 deaths due to COVID-19, 4,014 (3.2%) were classified as "suspected" COVID-19. Including all 139,658 deaths involving COVID-19, "suspected" COVID-19 was recorded on 3.3% (4,591 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 Kanak Ghosh, Matt Wells, Layli Semple, Alexander Cooke, and Heidi Wilson 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 2020 and 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.