… We are still struggling to understand coronavirus. I can think of no time in my medical career when it has been more important to have accurate diagnosis of a disease, and understanding of precisely why patients have died of it. Yet very early on in the epidemic, rules surrounding death certification were changed — in ways that make the statistics unreliable. Guidance was issued which tends to reduce, rather than increase, referrals for autopsy.
Normally, two doctors are needed to certify a death, one of whom has been treating the patient or who knows them and has seen them recently. That has changed. For Covid-19 only, the certification can be made by a single doctor, and there is no requirement for them to have examined, or even met, the patient. A video-link consultation in the four weeks prior to death is now felt to be sufficient for death to be attributed to Covid-19. For deaths in care homes the situation is even more extraordinary. Care home providers, most of whom are not medically trained, may make a statement to the effect that a patient has died of Covid-19. In the words of the Office for National Statistics, this ‘may or may not correspond to a medical diagnosis or test result, or be reflected in the death certification’. From 29 March the numbers of ‘Covid deaths’ have included all cases where Covid-19 was simply mentioned on the death certificate — irrespective of positive testing and whether or not it may have been incidental to, or directly responsible for, death. From 29 April the numbers include the care home cases simply considered likely to be Covid-19.
So at a time when accurate death statistics are more important than ever, the rules have been changed in ways that make them less reliable than ever. In what proportion of Covid-19 ‘mentions’ was the disease actually present? And in how many cases, if actually present, was Covid-19 responsible for death? Despite what you may have understood from the daily briefings, the shocking truth is that we just don’t know. How many of the excess deaths during the epidemic are due to Covid-19, and how many are due to our societal responses of healthcare reorganisation, lockdown and social distancing? Again, we don’t know. Despite claims that they’re all due to Covid-19, there’s strong evidence that many, perhaps even a majority, are the result of our responses rather than the disease itself.
It might have been possible to check these proportions by examining the deceased. But at a time when autopsies could have played a major role in helping us understanding this disease, advice was given which made such examinations less likely than might otherwise have been the case. The Chief Coroner issued guidance on 26 March which seemed designed to keep Covid-19 cases out of the coronial system: ‘The aim of the system should be that every death from Covid-19 which does not in law require referral to the coroner should be dealt with via the [death certification] process.’ And even guidance produced by the Royal College of Pathologists in February stated: ‘In general, if a death is believed to be due to confirmed Covid-19 infection, there is unlikely to be any need for a post-mortem examination to be conducted and the Medical Certificate of Cause of Death should be issued.’
We need proper information to inform our responses to the virus, both clinical and societal. Instead, we have no idea how many of the deaths attributed to Covid-19 really were due to the disease. And we have no idea how many of the excess deaths were really due to Covid-19 or to the effects of lockdown. Officials should be releasing, as a matter of urgency, detailed information on the surge in deaths, both apparent Covid and non-Covid — particularly in care homes. How many are dying of Covid acquired in hospitals? Data presumably exists on this too, but is not released….