The deadly numbers game: Covid-19 and the death certificate

Recording and comparing deaths from Covid-19 – every one of them a tragedy for families and individuals – should demand the highest possible transparency and clarity. But the reality falls far short.

As of April 30, the death toll in the UK for Covid-19 stood at 26,771 according to the government. It is now, officially, the highest in Europe. The official figures now take into account non-hospital deaths when tested positive for the virus. The Financial Times was already putting the true number of deaths at twice the official figures (1).  a useful metric may be Covid-19 deaths per million (2). At the end of April this was 388 for the UK, 452 for Italy, 509 for Spain and 632 for Belgium, but only 82 in Germany (3). Belgium’s figures include all the deaths in the country’s more than 1,500 nursing homes, even those untested for the virus; these numbers add up to more than half of the overall figure. In stark contrast to the UK’s approach, Belgian Prime Minister Sophie Wilmés explained the government chose: “full transparency when communicating deaths linked to Covid-19,” even if it leads to “numbers that are sometimes overestimated.” (3).

In the UK, the final official death toll will depend in some part on the discretion of thousands of doctors as to whether Covid-19 is recorded on the death certificate. Only around 70% of patients with the disease test positive. There does not have to be a positive isolate of virus from test swabs as long as the symptoms are consistent with coronavirus infection. Discretion could lead to an under count in the number of fatalities rather than an over count, which is one of the reasons why looking at ‘excess deaths’ is another important way of assessing how many victims there have been. ‘Excess deaths’ are the number of deaths above what statistically would have been expected from deaths in previous years. They are a good indicator of how many people may have died as a result of Covid-19 (4). Most routine mortality statistics are based on the underlying cause. Underlying cause statistics are widely used to determine priorities for health service and public health programmes and for resource allocation, but one of the reasons for death certification is that: “Information . . .  is used to measure the relative contributions of different diseases to mortality”. This is clearly particularly important during a pandemic when meagre availability of testing for Covid-19 means the only hard figures relating to prevalence of infection are from this diagnosis being added to death certificates where appropriate.

Astonishingly, at least one hospital issued guidance to its doctors stating that it was not necessary to put Covid-19 down as a cause of death on the death certificate and offered “community acquired infection” as an alternative (5). Under pressure from press enquiry, the hospital then retracted the advice, but whether this was an isolated incident or part of a wider problem remains uncertain.

There is no official record of the occupation of people who have died from coronavirus. Ministers when interviewed have often been uncertain of overall numbers of deaths among health and care staff. By 1st May, the government said there had been 49 verified deaths of UK health workers from Covid-19 (6), but it is clear that this was a gross underestimate. In fact, by searching for reports published in the media the Guardian newspaper had recorded a total of 144 deaths (6), very similar to the figure arrived at by KONP (7). The true number is likely to be even higher because not all deaths will be in the public domain.

Covid-19 is a statutorily notifiable disease that must be reported to public health authorities. Notification is done so that action can (if necessary) be undertaken; and therefore has to be done promptly, on suspicion, without awaiting confirmation (8). In an occupational setting, any harm or near misses must be reported to the Health and Safety Executive under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (9). This covers any worker who “has been diagnosed as having Covid-19 and there is reasonable evidence that it was caused by exposure at work. This must be reported as a case of disease” as must any worker who “dies as a result of occupational exposure to coronavirus” (9).

There is also an obligation for doctors to report deaths to the coroner where occupational exposure to a pathogen may have been a factor (9). Trade unions have repeatedly warned that their members do not feel safe at work because of a lack of PPE. the chief coroner for England and Wales has issued guidance that: “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”(10). Coroners, however, would still be able to require testimony from such as the nameless managers who refused requests for PPE from Dr Peter Tun (11).

An awareness of what is required from death certification, and reporting to public health, the HSE and the coroner will together provide a more complete picture of overall deaths as well as those specifically among health and care workers and others with public facing employment. ‘Excess deaths’ and deaths/million population will also be very important metrics. Identifying occupational risk is the least we can ask on behalf of those who have died while working for the public good.


Dr John Puntis
Co-Chair, Keep Our NHS Public

[Abridged version. You can download the full version here.]









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