Accurate accounting is part of honouring the dead: the Government should start with transparency and humility
The UK looks on course to be one of the worst affected countries in Europe with respect to deaths from coronavirus. While this should prompt careful and critical examination of how the Government has handled the crisis, we can already see an attempt to obscure the reality that too little was done too late.
Prime Minister Johnson has referred to our “success” in responding to the pandemic as part of constructing a narrative that diverts attention away from his own incompetence. This was too much even for some of the right-wing press. There is also plenty of scope to muddy the waters in terms of the scale of the disaster.
Transport Secretary Grant Shapps, when asked about the government failing to keep deaths down, said:
“ . . .there are other factors to take into account on excess mortalities which we don’t know about today. For example, what does it do in terms of other illnesses and diseases, and what was the impact?”
He said the demographics of a country, obesity rate, geography and population density would also have an impact on interpreting excess mortality. Clearly government ministers are getting some training from epidemiologists on how to deflect difficult questions.
As of April 30, the death toll in the UK stood at 26,771 according to the government. 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. Making international comparisons is far from straightforward not least because countries record their deaths in different ways. The statistician, David Spiegelhalter, has suggested that a useful metric may be Covid-19 deaths per million. 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. Belgium may be at the top of the list, but its 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.”.
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.
The Medical Certificate of Cause of Death is set out in accordance with World Health Organisation (WHO) recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD). The doctor signing is asked to start with the immediate, direct cause of death, then to go back through the sequence of events or conditions that led to death until the one that started the fatal sequence is reached. This means that the condition at the bottom of the list will have caused all of the conditions above it, and will usually be selected as the underlying cause of death, following the ICD coding rules. For example, if Covid-19 were to send someone’s diabetes spiralling out of control with the result that they died after a period of intensive care with coronavirus lung disease, diabetes would be given as the cause of death (diabetes being a predisposing condition to coronavirus infection). Above this on the list would also be any other medical conditions they might have, and top of the list, Covid-19 as the precipitating cause of death.
The logic of this is that from a public health point of view, preventing diabetes would have resulted in the greatest health gain. 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. Keep Our NHS Public (KONP) received a press enquiry about this story and fed back relevant information showing that it was clearly going against accepted guidance. Writing to the Trust concerned, the Good Law Project then threatened to apply for judicial review unless the guidance was withdrawn, on the grounds that it was irrational, demonstrated a material error of law, and breached the European Convention on Human Rights. The hospital then retracted the advice, but whether this was an isolated incident or part of a wider problem remains uncertain.
Deaths of workers from occupational exposure
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, 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, very similar to the figure arrived at by KONP. 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. 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. 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”.
There is also an obligation for doctors to report deaths to the coroner where occupational exposure to a pathogen may have been a factor. Trade unions have repeatedly warned that their members do not feel safe at work because of a lack of PPE. It is therefore regrettable the chief coroner for England and Wales, Mark Lucraft QC, 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”. This prompted Lord Falconer, the shadow attorney general to comment: “I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker. This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.” Coroners, however, would still be able to require testimony from such as the nameless managers who refused requests for PPE from Dr Peter Tun.
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 such as bus drivers. ‘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.
John Puntis is a paediatrician and co-chair of Keep Our NHS Public. This article appeared in a shorter form in the BMJ Rapid Response section.