statistics Health Quarterly IN THIS ISSUE Autumn 1999 Page In brief Health indicators

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1 Health statistics Quarterly 03 Autumn 1999 IN THIS ISSUE In brief Health indicators Recent trends in deaths from homicide in England and Wales Examines trends in deaths from homicide using routine death registration data and compares these to data from the Home Office Cleo Rooney and Tim Devis Road traffic deaths: trends and comparison with DETR figures Compares ONS and DETR data and explores trends in road traffic mortality between 1982 and 1997 Olivia Christophersen, David Dix and Cleo Rooney Multiple congenital anomalies in England and Wales Presents new data on multiple congenital anomalies and describes how these data will be used for international comparisons Beverley Botting, Rolv Skjaerven, Eva Alberman and Carole Abrahams Social patterning of health and mortality: children, aged 6 15 years, followed up for 25 years in the ONS Longitudinal Study Examines the relationship between health and socio-economic circumstances at different stages of the life course of children aged 6-15 years, followed up for 25 years in the ONS Longitudinal Study Seeromanie Harding, Michael Rosato, Joanna Brown and Jillian Smith Annual Update: 1997 Mortality statistics: injury and poisoning (England and Wales) Tables List of tables Notes to tables Tables Reports: Infant and perinatal mortality 1998: health areas, England and Wales Sudden infant deaths 1998 Death registrations in England and Wales, 1998: area of residence Recent ONS publications Page London: The Stationery Office A publication of the Government Statistical Service

2 in brief Changes to boundaries of Regional Offices The boundaries of the NHS Executive Regional Offices (ROs) changed on 1 April The former Regions of Anglia and Oxford, North Thames and South Thames were replaced by a new regional structure, as follows: a London RO, which covers the 16 health authorities in Greater London; a South East RO, which covers the 14 health authorities of East Kent, West Kent, East Sussex Brighton and Hove, West Sussex, East Surrey, West Surrey (all formerly in the South Thames RO), Isle of Wight, Southampton and South West Hampshire, Portsmouth and South East Hampshire, North and Mid Hampshire (formerly in the South and West RO), Berkshire, Buckinghamshire, Oxfordshire and Northamptonshire (all formerly in the Anglia and Oxford RO); an Eastern RO, comprising the eight health authorities of West Hertfordshire, East and North Hertfordshire, South Essex, North Essex (formerly part of North Thames RO), Bedfordshire, Cambridgeshire*, Norfolk* and Suffolk (all formerly part of the Anglia and Oxford RO). As a result of these changes, the South West RO now excludes the Isle of Wight and the three Hampshire health authorities (noted above). * Norfolk and Cambridgeshire health authorities were created from 1 April 1999, replacing the three former health authorities of Cambridge and Huntingdon, East Norfolk and North West Anglia. Number of births in 1997 Since publication of 1997 births data, an error has been discovered on the births database. A technical problem resulted in 1,002 records being excluded from the published analysis. The revised total number of births for 1997 is thousand of which 3.4 thousand were stillbirths. The total fertility rate remains unchanged at Reference tables 2.1, 2.2, 3.1 and 3.2 have been revised to show the correct figures and more information will appear in Births statistics 1998 (Series FM1 no. 27) which will be published in December Published 1998 births data are unaffected by this problem. Contraception and health The ONS Omnibus Survey was used to mount a series of questions on contraception for several months in 1997/8. The results show that one in seven women aged 16 to 49 were not in a sexual relationship and one in eight were not using a regular form of contraception, but for those who were using contraception three methods predominated. The contraceptive pill was the most popular method, mentioned by a quarter of women in the age group. The condom was the next most common method but the permanent method of sterilisation was just as popular. Other topics covered in the study included the use of emergency contraception, condom use in relation to sexual health, and knowledge of sexually transmitted diseases. The data form one of the main sources of information on contraceptive use and sexual health. Questions were put to 7,500 adults at randomly selected addresses in Britain and a report has been published by Social Survey under the title Contraception and Sexual health, For further information about the Omnibus Survey contact Olwen Rowlands on Figure A Pill Sterilisation Condom Intrauterine device Withdrawal Cap Safe period Other methods None No sexual relationship Use of contraception: Great Britain, Percentage of women aged Psychiatric morbidity among prisoners Two new reports based on further analysis of data from the Survey of Psychiatric Morbidity among Prisoners in England and Wales were published by ONS on 27th July The survey, which was carried out by the Social Survey Division of ONS on behalf of Office for National Statistics 2

3 the Department of Health, covered all prisons in the country and involved interviews with about 3,200 prisoners during the last quarter of The main report of the survey was published in October 1998.* The two new reports contain the results of additional analyses which focus in more depth on two topics of particular importance within the prison population: substance misuse and non-fatal suicidal behaviour. Substance misuse among prisoners in England and Wales (by Nicola Singleton, Michael Farrell and Howard Meltzer) brings together information on substance misuse from the main report with the results of a range of additional analyses such as smoking, age of initiation of drug use and more details of treatment for drug use. In addition, it considers the co-occurrence of use of tobacco, alcohol and illicit drugs and their association with mental disorder. High rates of substance misuse before coming to prison were found among all sample groups. The survey found very high levels of smoking among the prison population: 85 per cent of male remand, 78 per cent of male sentenced, 83 per cent of female remand and 81 per cent of female sentenced prisoners were current smokers. These rates are much higher than seen in the general population and closer to levels reported in surveys of homeless people and residents of institutions catering for those with mental illness. A large proportion of both male and female respondents reported a hazardous pattern of drinking in the year before coming to prison. Among the men, 58 per cent of remand prisoners and 63 per cent of sentenced prisoners reported hazardous drinking. The equivalent figures for the women in the sample were 36 per cent of remand and 39 per cent of sentenced prisoners. Very high rates of drug use and dependence prior to coming to prison were also found, with rates among remand prisoners being slightly higher than among sentenced prisoners. Among male remand prisoners, 10 per cent reported moderate drug dependence and a further 40 per cent severe drug dependence (three or more symptoms of dependence), while 11 per cent of male sentenced prisoners reported moderate and 32 per cent severe dependence in the year before coming to prison. Among the women the equivalent figures were 7 per cent of remand prisoners reporting moderate dependence and 47 per cent severe dependence with 8 per cent reporting moderate and 34 per cent severe dependence among sentenced prisoners. Among male remand prisoners, 38 per cent reported having used drugs during their current prison term as did 48 per cent of male sentenced, 25 per cent of female remand and 34 per cent of female sentenced prisoners. The drug most frequently used was cannabis, followed by heroin other drugs were mentioned far less frequently. Respondents reported starting to use drugs at a young age, with more than half starting to use one of the six drugs considered in detail in the survey before the age of 16. The median age for starting cannabis use was the lowest (about 15), followed by amphetamines, then heroin and cocaine powder, with crack use commencing later at around 21 years. About one in five of the men in the sample who had used at least one of the six drugs covered in detail in the questionnaire at some time, reported having first used one of them in prison. Women were less likely to report starting to use drugs in prison less than one in ten remand prisoners and about one in seven sentenced prisoners said a first episode of use had occurred in prison. The vast majority of respondents (over 85 per cent) reported either smoking, hazardous drinking or drug dependence in the year before coming to prison. The co-occurrence of substance misuse was also very common: 73 per cent of male remand, 68 per cent of male sentenced and female remand and 55 per cent of female sentenced prisoners reporting two or more out of smoking, hazardous drinking or drug dependence. The survey also found high rates of co-occurrence of mental disorder and substance misuse. The section of the questionnaire on drug use included questions on treatment, help or advice for drug problems received both within and outside prison. A third of the men and half of the women assessed as being dependent on drugs in the year prior to coming to prison reported receiving some sort of help for their drug problem in that year before imprisonment. Considerably lower proportions reported receiving help during their current prison term (ranging from 20 per cent of male remand prisoners to 32 per cent of female sentenced prisoners). The exception to this was among the male sentenced group but this may be an artefact of the time spent in prison. Those dependent on opiates were more likely than those dependent on other drugs to report receiving help or treatment both outside and in prison. The most common sources of help for drug problems outside prison were Community Drugs Teams and GPs or other practice staff. Within prison, remand prisoners usually cited prison medical staff as their source of help but sentenced prisoners mentioned outside agencies as the source of help as frequently as they mentioned prison staff. Women were more likely than their male counterparts to report having been prescribed methadone both before and in prison, but there was no difference between remand and sentenced respondents. About one in three women and one in six men reported receiving methadone treatment in the year before prison and nearly one in four women in the month before prison. These proportions decreased slightly to about one in ten men and one in four women when treatment in the month before coming to prison was considered. In general a smaller proportion reported receiving treatment with methadone while in prison for the current offence than had been receiving it in the month before coming to prison. The impact of coming to prison on continuity of treatment for drug problems is illustrated by the finding that less than a third of those who reported receiving methadone treatment in the month before coming to prison had received methadone in the month immediately after coming to prison. Overall, the report indicates very high levels of morbidity associated with tobacco, alcohol and drug consumption. Given the high rates of problems, the levels of help reported are limited both within the community and the prison setting. The report on Non-fatal suicidal behaviour among prisoners (by Howard Meltzer, Rachel Jenkins, Nicola Singleton, John Charlton and Mohammed Yar) identifies various factors which distinguish those prisoners who had attempted suicide in the past year from those who had not. Within the analysis male and female, remand and sentenced prisoners were considered separately. Since the majority of prisoners had been in prison for less than a year at the time they were interviewed, most of these suicide attempts will have occurred outside prison. Therefore it is not surprising that most of the factors associated with nonfatal suicide attempts are personal rather than prison characteristics. Eight factors emerged as distinguishing between prisoners who had and had not attempted suicide in the past year. Prisoners who had attempted suicide tended to be younger, white, suffer from a psychotic disorder or have a severe neurotic disorder, take psychotropic medication, have had a stay in hospital for a mental illness, have poor social support and have experienced several, stressful lifetime events. The data analysis also showed that different factors were relevant for men and women and for remand and sentenced prisoners. Prisoners who attempted suicide in the past year tended to be young, white, single, born in the UK and to have left school early and be poorly educated. Ethnicity and age were the most significant of these relationships. Psychosis was found in about 5 per cent of the non-suicidal group, but its prevalence was substantially increased to between a quarter and a half of those who had attempted suicide in the last year. Neurotic disorder and alcohol abuse, while both being fairly common among prisoners were both much more common in prisoners who had tried to kill themselves in the last year. Current psychotropic medication was three times more likely in male prisoners and two to three times more likely in female prisoners who had attempted suicide in the previous year compared with those who had not. Previous admission to a mental hospital was two to three times more likely in male prisoners and five to six times more likely in female prisoners who had attempted suicide in the previous year compared with those who had not. Suicide attempters were more likely to have very small primary support groups and to have a severe lack of social support. Suicide attempters were also much more likely to have experienced a variety of adverse life events, both in the last six months and over the course of their lifetime, particularly violence or sexual abuse. These two reports are available through ONS Direct on , price 15 each. * Singleton et al, Psychiatric morbidity among prisoners in England and Wales, ISBN , price 45, is available from The Stationery Office. 3 Office for National Statistics

4 Health indicators England and Wales Figure A Population change (mid-year to mid-year) Thousands Mid-year Natural change Net migration and other changes Total change Figure B Age-standardised mortality rate Rate per million population 20,000 15,000 10,000 5, * * Provisional data. Year Figure C Infant mortality (under 1 year) Rate per 1,000 live births * * Provisional data. Year Figure D Quarterly abortion rates residents Rate per 1,000 women Abortion rate 9 Moving average rate Provisional rate Year Office for National Statistics 4

5 Recent trends in deaths from homicide in England and Wales Cleo Rooney and Tim Devis, ONS DATA ON HOMICIDES FROM DEATH REGISTRATIONS Timely statistics on the annual number of homicides are difficult to produce, if these are based on death registrations. Information about these deaths only becomes available after legal processes which may take many months to complete. Devis and Rooney found that in 1994 the median time to register a death eventually coded to homicide after its occurrence was 3.2 months, compared with 2.6 months for all deaths from external causes of injury and poisoning and only one day for deaths from natural causes. 1 However, this was an analysis of deaths occurring in 1994 which had been registered by November 1995, and at that point there were still many possible homicides yet to be assigned their correct underlying cause of death. Five per cent of eventual homicides were not registered within a year of the death occurring. Thus a median delay of 3.2 months for homicides is almost certainly an underestimate. In England and Wales, all suspicious deaths, including all those due to accidents or violence, must be reported to the coroner for investigation before they can be registered. 2,3 The coroner will usually order a post mortem examination before opening an inquest. If the police report at this point that charges are to be brought against anyone or that the death is being investigated as homicide but the perpetrator has not been identified, the coroner adjourns the inquest to await the results of investigation and legal proceedings. There are difficulties in using data from routine death registration to study mortality from causes which are subject to lengthy investigation. However, once the effects of adjourned inquests, delayed registration and re-coding have been overcome, it is apparent that there has been an increase in homicide rates in young men over the last 20 years. Despite some decline in homicide rates at other ages, the highest rates are still in infants while the lowest rates in both sexes are in children aged The increases in homicides in young men and the decrease in older men are similar to recent trends in suicides. Since 1978 it has been possible to register deaths at this point the so called accelerated registrations. 4 The coroner sends the registrar a certificate of cause of death after inquest adjourned. This gives information on the injuries found at autopsy, and may give the mechanism of injury (eg crushing, fire) but no verdict. ONS assigns a temporary underlying cause code of E9888 (injury by other specified 5 Office for National Statistics

6 means, undetermined whether accidentally or purposely inflicted) 5 to these deaths. Since 1993 ONS has also coded coroner s verdicts or manner of death. Adjourned inquest deaths are assigned a code indicating that the verdict is still pending investigation. Injuries are coded as normal to chapter XVII of ICD 9. The coroner will normally update ONS with the final verdict and cause of death when these are known, which may be months or years later. ONS then updates the coding on its dynamic national mortality database 3 which holds information on deaths since the beginning of January Convictions for murder, manslaughter, and offences under the Children Act, or Health and Safety at Work Act are used by ONS to assign the underlying cause of death to homicide (ICD9 code E960 E969) (Box One). A conviction for causing death by dangerous driving, and even a manslaughter verdict for a motor vehicle death, will result in coding to a motor vehicle traffic accident (E810 E819). ONS, like most compilers of vital statistics, uses an epidemiological definition of homicide (that one person has been killed by another, not accidentally) rather than a strict legal definition. ONS would still code a death as homicide, for example, if the perpetrator was found not guilty by reason of insanity or could not be prosecuted. If ONS is informed that the court or coroner has found that the death was in fact an accident or suicide, the underlying cause of death is re-coded to reflect this. In other cases, where legal proceedings have already been completed or the death is known to have been homicide but no prosecution is possible, the coroner completes the inquest before issuing a certificate of cause of death. The certificate then includes the injuries, external cause and coroner s verdict or verdict of a higher court, if there has been one, as to the intent of the perpetrator. Where the perpetrator has Box one HOMICIDE: VERDICTS, DEFINITIONS AND ICD 9 CODES Verdicts used in ONS to code deaths to homicide (E960 E969) Unlawfully killed Homicide Murder Manslaughter (except in motor vehicle deaths - see text) Causing death by: Cruelty under the Children and Young Persons Act Negligence under the Health and Safety at Work Act Broad cause groups Definite homicide Accelerated registration/probable homicide Total homicide (definite and probable homicide) External cause groups homicide mechanism Struck Fire or scald Poisoning Suffocation Drowning Firearms Cutting/piercing Pushed Other specified Unspecified Injury groups Skull fracture Intracranial injury, including haemorrhage Injury to heart, lung and intra-thoracic organs Open wounds and injuries to blood vessels of: head and neck chest other and unspecified sites Poisoning Asphyxiation Other specified injuries Unspecified injuries, including multiple injuries ICD 9 E960 E969 E9888 with verdict pending investigation E960 E969 and E9888 with verdict pending investigation ICD 9 E9600, E9682 E961, E9680, E9683 E962 E963 E964 E9650 E9654 E966 E9681 E9601, E965, E967, E9684, E9688 E9689, E969 and E9888 with verdict pending ICD , 900, 920, 921, , 876, 901, 911, 922, , 884, , , 914, , 878, 902, , 924, 952, 958, 991, 993, 995, 997, 998, 9941, , , 919, 929, 959 Office for National Statistics 6

7 Figure 1 Deaths from homicides in England and Wales : original and updated numbers from ONS and Home Office Number of deaths Year ONS E960 E969 as published ONS total E960 E969 and E9888 'pending' HO currently recorded ONS E960 E969 latest from database HO initially recorded died, by suicide or other means, ONS uses the coroner s inquest verdict (usually unlawful killing ) to assign the death to homicide. These processes are described in detail in the latest ONS annual publication on deaths from injury and poisoning. 6 Deaths on the dynamic database coded to E988.8 at any given time will include: 1 Deaths where an inquest has been adjourned and which have been assigned this code, and a pending manner of death, as a temporary measure (as described above). Most of these will eventually be re coded on receipt of further information, and all but a few will be re coded either to homicide or to motor vehicle traffic accidents. 2 A very small number of deaths registered after a completed inquest which delivered an open verdict, and a cause of death of injury or poisoning which could not be assigned to any more precise code for death by injury and poisoning of undetermined intent (E980 E989). These deaths will retain the E9888 code for underlying cause of death. When the 1995 annual extract was taken from this dynamic database (in September 1996) 361 deaths were assigned to code E988.8 in total, of which 28 had received an open verdict at an inquest and 333 were adjourned pending investigation. By May 1998 the total number of 1995 deaths coded to E988.8 had fallen to 178, of which 32 had received an open verdict and 146 were still pending two and a half years after the end of the data year. 6 When other (minor) re-coding was taken into account it was found that 205 deaths for 1995 had been reassigned from code E988.8 of which about nine out of every ten were eventually coded to homicide. We can thus make three separate estimates of the number of annual deaths from homicide: 1 The number coded to ICD9 E960 E969 (homicide). This is the basic ICD classification, to which all homicides should eventually be assigned. 2 The number coded to E960 E969, plus those coded to E This takes account of accelerated registrations, most of which are eventually coded to a homicide code. This is a simple adjustment, using published figures by underlying cause, without requiring knowledge of the progress of inquest proceedings. It will include a handful of deaths which were almost certainly not homicides, since the inquest verdict was open. 3 The number coded to E960 E969, plus those coded to E988.8 where the verdict is pending. This allows more exactly for accelerated registrations which are likely to finish up coded to homicide. For some purposes it might be appropriate to include deaths coded to motor vehicle traffic accidents with a manslaughter verdict, or even a serious driving offence. ONS is examining these alternatives at present, and may present annual statistics for homicides in an amended form in the future. 6 Homicides estimated by including deaths on which we do not have final information may appear too uncertain to be of much use. However, comparing these figures with those produced by the Home Office provides some reassurance. Unlike ONS, the Home Office uses a legal definition of homicide in their statistics. Home Office figures are based on the year in which the offence was first recorded by the police, which may not be the year that the death occurred or was registered. The initial number recorded for the year may subsequently be reduced as a result of decisions by the police or the courts that no offence of homicide took place. 7 It cannot ever increase. Revised figures which take account of these changes are published regularly by the Home Office. 7 Office for National Statistics

8 Figure 2 Rate per million Average age-specific mortality rates from homicide and probable homicide (E960 E969 and E988.8 pending combined) in England and Wales by sex Figure 3 Percentage Method of homicide: England and Wales from Home Office as currently recorded* Male < Female Age group plus ONS deaths data are tabulated by the year in which they occurred, and figures for homicides which occurred in a given year are now revised upwards to take account of late registration, re coding or reregistration. Though the figures cannot therefore be matched exactly, they do show very similar patterns and trends since about In the 1950s numbers from death registrations were considerably lower than homicides recorded by the Home Office, and may have been incomplete. The closest correspondence is between Home Office figures for deaths initially recorded as homicide, and ONS total figure that is the sum of deaths certified as homicide, and coded to E960 E969 in time for routine annual publication, plus deaths certified after adjourned inquest coded to E9888 with verdict pending (Box One, Figure 1). Figure 1 also illustrates the variation which may occur in ONS annual figures due to differences in how long after the end of the data year the data are extracted and analysed. The number of deaths coded to homicide in the 1993 annual publication was the highest ever, whereas the total including E9888 pending was similar to the surrounding years. The reason is that the annual extract for 1993 was taken 15 months later than usual, because of changes in our computer systems. By that time, ONS had received updates on a much larger proportion of accelerated registrations than usual. A previous article by Noble and Charlton 8 looked at trends in homicides in England and Wales up to 1992, and discussed some of the problems of using routine registration data. They showed that there had been substantial increases in crude homicide rates between 1950 and 1980, after which rates were largely stable up to We have taken this opportunity to re-examine homicide mortality by year of death since 1979 using all available data, including late registrations and corrections to the cause of death codes. Because the number of deaths is fairly small we grouped them into five-year periods. One period, 1989 to 1992, is only four years. We chose to split the data between 1992 and 1993 because of the major changes in handling and processing which began in Women Men Persons Not known Burning Other Shooting Strangluation Hitting kicking etc Blunt instrument Sharp instrument * Source: Criminal Statistics, England and Wales TSO, Includes all currently recorded homicides 85 per cent of those initially recorded. THE CURRENT PICTURE OF HOMICIDE IN ENGLAND AND WALES Homicide is a rare cause of death in England and Wales accounting for about one in every 800 deaths, and about 4.4 per cent of deaths from any form of injury or poisoning (accidents and violence, E800 E999). Because the overall numbers are small and vary from year to year, we have combined data on deaths which occurred in the five years 1993 to 1997 to describe the current pattern of deaths from homicide. Box One shows the ICD 9 code groupings and definitions used in this article. Death rates due to homicide are generally higher in males than in females, the male to female ratio being highest in young adults and lowest in children and the elderly (Figure 2). By far the highest homicide rates in both sexes are in infants, with 44 homicides per million per annum in males and 35 per million in females. Once past infancy, rates fall rapidly so that they are lowest in both sexes between the ages of 5 and 14. They rise again in young adults, with a plateau around per million in women from age 20 to 49, falling to around 5 per million in middle age then rising in those over 80 to around 12 per million. Men show a second peak around 33 per million in their twenties which gradually falls to a low of 10 per million around 70 years of age, then rises again to 14 in those aged 85 and over. METHODS OF HOMICIDE AND TYPE OF INJURY SUFFERED Because we have included deaths for which final information was not available, a remarkably large proportion of all homicides and probable homicides combined are assigned to unspecified codes as their underlying cause. Adjourned inquests (E9888 pending ) make up 27 per cent of all definite and probable homicides in the five years between 1993 and 1997, and E9689 (homicide by unspecified means) and E969 (homicide due to late effects of any type of injury purposefully inflicted) together a further 22 per cent. For deaths before Office for National Statistics 8

9 Figure 4 Injury type by age group: total homicides (E960 E969 and E988.8 pending ), England and Wales Percentage of all homicides in age group 100 Males Under plus Total Age group Percentage of all homicides in age group 100 Females Under plus Total Age group Unspecified injury including 'multiple' Open wound and injuries to blood vessels, chest Other specified injury Open wound and injuries to blood vessels, head and neck Asphyxiation Injury intrathoracic organs Poisoning Intracranial injury and haemorrhage Open wound and injuries to blood vessels, other and unspecified Skull fracture 1993 this is even worse for most years since 1979, per cent of all homicides were registered without an external cause being specified (coded to E9888). Though some of these were updated later, and the numbers assigned to homicide were published, the data are no longer available for analysis in any detail. However, figures published by the Home Office on criminal statistics 7 do include methods of homicide per cent of deaths currently recorded as homicides by the police and Home Office have an apparent method reported (this represents approximately 85 per cent of those initially recorded as homicide) (Figure 3). Assault with a sharp instrument (stabbing) is the commonest method in males (38 per cent in ), followed by hitting or kicking (19 per cent), shooting (12 per cent) and blunt instruments (11 per cent). In females, stabbing (28 per cent) and strangulation or asphyxiation (27 per cent) together account for more than half of homicides while hitting and kicking and blunt instruments each make up about 11 per cent. Information on the secondary cause or main injury to the victim is much better than that on method in ONS data only about 10 per cent are assigned to unspecified injuries or multiple injuries. Figure 4 shows the distribution of main injury by age and sex. Over 60 per cent of all infant killings are due to skull fracture or intracranial injury, including haemorrhage. About 10 per cent are from suffocation or strangulation, and one in five due to other or unspecified 9 Office for National Statistics

10 Figure 5 Deaths per million infants Infant homicide rates (total homicides, including neonates) in England and Wales by sex Male Female Year of death kinds of injury. The pattern of injury at other ages is very different. In older children there are very few head injuries, while poisoning, asphyxia and other specified causes account for over 60 per cent in both girls and boys. In young men about a third of all homicides are due to open wounds and injuries to blood vessels of head, neck and trunk, and about 15 per cent to injuries to heart, lung and intrathoracic organs, injuries which are consistent with stabbing as the commonest method. In young women, a slightly smaller proportion (and therefore a much smaller number) are attributable to open wounds, considerably less to intrathoracic injuries and far more to asphyxiation, consistent with the higher proportion due to strangulation or suffocation as method. TRENDS FROM 1979 TO 1997 In infants there is considerable year to year variation because of the small numbers, but no evidence of any trend between 1979 and 1997 (Figure 5). Average age-specific rates in women up to 69 years old are very similar in the four periods since 1979 (Figure 6). Rates in men however have risen in age groups between 15 and 44 and in those aged 50 54, while remaining steady in those aged (Figure 6). There was a 55 per cent increase in men aged 30 34, from 18 to 28 homicides per million annually. In men aged the average rates rose from 23 to 33 per million (a 47 per cent increase). Rates have actually fallen in both men and women aged 75 and over. The greatest fall is 51 per cent in men over 85, who were at higher risk of homicide than men at any other age in the earlier period, but are now at lower risk than men aged The figures for 1997, and to a lesser extent 1996, which are based on data as at the end of December 1998 may not yet be complete. However the expected further increase based on past experience would not be more than 1.5 per cent for 1996 deaths and 4 per cent for Thus the average rates for are not likely to underestimate the increase, or overestimate the fall, in these age-specific rates by a significant amount compared to the size of the observed changes. The higher rates of death from homicide in men than women are similar to the pattern of deaths from injury and poisoning as a whole. Deaths from disease are infrequent in young adults, so injury and poisoning comprise a large proportion of deaths. Overall mortality rates from all causes at ages have fallen between 15 and 20 per cent in women since 1979, but in men falls have been much more modest. Rates of all cause mortality have actually risen in year old men. 10 Deaths from many causes contribute to these changes. In particular, suicide, including injury and poisoning of undetermined intent, rose by 30 per cent in men aged 25 to 34 between 1983 and Rises in suicides in men aged and were more modest, while those in older men and women were falling or stable. 11 Similarly, drug-related deaths (poisoning with drugs whatever the intent, drug dependence and drug abuse) have risen markedly in young men since the mid-1980s, but fallen in young women. 12 Motor vehicle traffic deaths, however, are lower in young men now than in 1979, though rates in age groups appear to have risen slightly in 1996 and Figure 6 Age-specific homicide rates in England and Wales by quinnquenia Rate per million 50 Males Rate per million 50 Females < Age group Office for National Statistics plus < Age group plus

11 Figure 7 Total homicides in men aged 15 44, by year of death and nature of injury Number of deaths Year of death Unspecified injury including 'multiple' Open wound and injuries to blood vessels, chest Other specified injury Open wound and injuries to blood vessels, head and neck Asphyxiation Injury intrathoracic organs Poisoning Intracranial injury and haemorrhage Open wound and injuries to blood vessels, other and unspecified Skull fracture Changes in homicide rates, particularly the falling death rates in older men and rising rates in young men, are very similar to those reported for suicide by Kelly and Bunting. 11 The age and sex distribution and time trends in deaths from homicides are also similar to those from other sorts of injury and poisoning except motor vehicle traffic accidents. The actual numbers of deaths though are much smaller. Even in year old men, homicide (including E9888 pending ) accounted for only 5.2 per cent of injury and poisoning deaths in (3.5 per cent of all deaths) whereas 27 per cent were suicide, 11 per cent undetermined intent, 36 per cent motor vehicle traffic accidents and 20 per cent other accidents. INJURIES AND METHODS OF HOMICIDE OVER TIME As for other types of external causes of death, information on injuries for homicides has been slightly less precise since This probably reflects changes in the coroner s certificate of cause of death after inquest. 9 The cause of death section is now in the same format as in the medical certificate of cause of death, and the coroner is no longer asked to list the types of injury and the body parts affected. This seems to have led to coroners recording less detail on injuries. As would be expected, a larger proportion of deaths certified after adjourned inquest and not yet updated (E9888 pending ) do not have details of main injury. Despite this, a main injury is coded for 90 per cent of homicides and probable homicides combined. Figure 7 shows a shift from skull fracture to intracranial injury in young male homicides, with no apparent overall increase. This shift has also been seen in motor vehicle traffic accident (MVTA) and other external causes of death 13 and is probably due to a change in certification practice by coroners and their pathologists using the new forms. There is also an apparent shift from injuries of intrathoracic organs to open wounds of head and trunk. Whether this is a real change in the pattern of injuries, or another change in certification practice, is not clear. We are unable to say which mechanisms of homicide have risen on the basis of ONS data, because of the problems outlined above. Home Office data 7,14 (Figure 8), show rises in the average number of homicides by sharp instrument, blunt instrument, hitting or kicking and shooting in compared to , and falls in strangulation and burning. The largest absolute rise is in homicides from sharp instruments, from an average 175 per year in to 211 per year in The greatest relative rise is in shooting, up 66 per cent. However, shooting still accounts for only about 10 per cent (up from 6 per cent) of all recorded homicides (on average 61 deaths per year in ). The changes in the pattern of method, particularly the increase in stabbings and shootings, are consistent with the rise in death rates from homicide in young men who are most often killed through open wounds and injuries to intrathoracic organs. SOCIAL CLASS Drever, Bunting and Harding 15 showed a steep social class gradient in standardised mortality ratios (SMRs) for homicide in England and Wales. In men aged in Social Class V (unskilled, SMR 300) were 12 times as likely to be killed as those in Social Class I (professional and managerial, SMR 25). Though this was based on only 482 definite homicides (E960 E969 only), the differences from the England and Wales figure were significant. 15 Deaths from accidents, suicide and undetermined injury all have an inverse relationship with social class, though that for homicide is much steeper than other external causes except for deaths from accidental poisoning Office for National Statistics

12 Figure 8 Average numbers of recorded homicides* in England and Wales and by method Figure 9 Average annual homicide rates by method of homicide: selected recent years for countries participating in ICE on injury Number of homicides Annual average HO (average total 532 homicides per year) Annual average HO (average total 619 homicides per year) United States 1995 Scotland Israel New Zealand Australia Canada England and Wales Denmark The Netherlands 1995 Norway France Deaths rate per million Source: ICE on Injury. 16 Cut/ pierce Firearm All other 50 0 Sharp instrument Source: Blunt instrument Hitting kicking etc Stranglulation or asphyxiation INTERNATIONAL COMPARISONS Shooting Explosion Burning Drowning Method Poison or drugs Motor vehicle ONS participates in an International Collaborative Effort on Injury Statistics, aimed at assessing and improving the comparability of routine vital and health statistics from a variety of countries. Recent comparisons of homicide rates in participating countries 16 (Figure 9) show that mortality rates from homicide in England and Wales are lower than those in Scotland, New Zealand, Israel, Australia and Canada, even after including adjourned inquest deaths. They were higher than Denmark, the Netherlands, Norway and France 16 (though French death registration figures almost certainly underestimate homicides and other injury deaths because the Institut National de la Santé et de la Recherche Médicale (INSERM) does not have access to cause of death information on deaths subject to forensic investigation). 17 The homicide rate in the USA is six and a half times that in England and Wales. Firearm homicides alone accounted for an extra 55 deaths per million population in the USA, 75 per cent of the total difference, reflecting the enormous differences in the accessibility of guns between the two countries. The difference between homicide death rates in these two countries varies markedly with age. Infants are only twice as likely to be killed in the USA as here, whereas the ratio in 15 to 19 year olds is 12.5 (Figure 10). Other Not known Criminal Statistics, England and Wales TSO, 1998, and same for 1989, HMSO, * Includes all currently recorded homicides 85 per cent of those initially recorded. DATA ISSUES AND WHAT ONS CAN DO ABOUT THEM The most serious problem with data on homicides from death registrations is timeliness. This is because these deaths cannot be registered until the coroner has completed an inquest, or adjourned it Figure 10 Rate per 100,000 population per year Age-specific homicide rates* per hundred thousand population in England and Wales and in the USA 00 < Age group England and Wales USA 1995 Ratio USA: England and Wales 85 plus * Males and females combined (note changed denominator to fit higher rates in USA). when legal proceedings in a higher court are likely. For deaths subject to inquest the delay from occurrence to registration has increased considerably from a few days or weeks in the 1960s to several months now. 1 Even registration after adjournment usually involves weeks of delay, and can take years (unpublished data). In Scotland all deaths are registered within a few days using information from the medical certificate of cause of death. Any later investigation or legal conclusion is used to correct the data when it becomes available. A similar system would only be possible in England and Wales if the law governing death registration was changed. Civil registration is currently under review by ONS with a view to modernising the service provided to the public. This and other changes may be possible at some stage. Office for National Statistics 12

13 In the meantime, many people need to make use of these data and cannot wait the two or three years needed to be sure that they are complete. At any given time, the best estimate of homicide mortality in preceding years is given by using deaths coded to E988.8 with verdict pending in addition to those coded to the homicide range. This may include a very small number of non-homicides but, depending on the length of time since the data year, it may also be short by a few deaths not yet registered. Unfortunately, this also means using data which are still missing information about cause of death, particularly the methods of injury. Since 1993, because the data are stored in a dynamic database, we can update them at any time. We now publish updated figures each year in the annual volumes of statistics on deaths from injury and poisoning. We are also able to provide current data extracts for users whose needs are not met by the routine publications. CONCLUSIONS Despite the difficulties with these data, we have shown some interesting trends and patterns which warrant further investigation. The similarities over the past two decades in changes in homicide rates with suicide rates (rising in young men while falling in the elderly), suggest areas for further research. The methods used for homicide and suicide are very different, but the social class pattern is similar. ONS plans further study of the geographic and temporal patterns of injury deaths. We are currently involved in further international studies aimed at improving data comparability, and exploring the differences in risk for particular population groups within countries, the variations in method or mechanism of injury and the determinants of the differing risks for various population groups between and within countries. Key findings The risk of dying from homicides is highest in babies and lowest in children aged Males are at greater risk of being killed than females at all ages. Death rates from homicides have fallen in the elderly over the past 20 years. While in younger men they have risen by about 50 per cent on average. Stabbings and shootings have both increased but shootings still account for only 10 per cent of recorded homicides. ACKNOWLEDGEMENTS The authors wish to acknowledge the International Collaborative Effort (ICE) on Injury Statistics for contributions to this research. The ICE is sponsored by the National Center for Health Statistics, UK Centers for Disease Control and Prevention, with funding from the National Institute of Child Health and Development, National Institutes of Health. We also thank Professor Lois Appleby for his helpful comments on an earlier draft. REFERENCES 1 Devis T and Rooney C. The time taken to register a death. Population Trends 88 (1997), Coroners Act Devis T and Rooney C. Death Certification and the epidemiologist. Health Statistics Quarterly 01 (1999), Office of Population Censuses and Surveys. Mortality statistics England and Wales; Deaths from injury and poisoning HMSO (London: 1980). 5 World Health Organisation. International Classification of Diseases, Ninth Revision. WHO (Geneva: 1977). 6 Office for National Statistics. Mortality statistics: injury and poisoning 1996, series DH4 no 21, pp xii xxi. TSO (London: 1998). 7 Home Office. Criminal Statistics England and Wales: TSO (London: 1998). 8 Noble B and Charlton J. Homicides in England and Wales. Population Trends 75 (1994), Rooney C and Devis T. Mortality trends by cause of death in England and Wales : the impact of introducing automated cause coding and related changes in Population Trends 86 (1996), Aylin P, Dunnell K and Drever F. Trends in mortality of young adults aged in England and Wales. Health Statistics Quarterly 01 (1999), Kelly S and Bunting J. Trends in Suicide in England and Wales, Population Trends 92 (1998), Christophersen C, Rooney C and Kelly S. Drug related mortality: methods and trends. Population Trends 86 (1996), Christophersen C, Dix D and Rooney C. Trends in motor vehicle deaths in England and Wales. Health Statistics Quarterly 03 (1999), in press. 14 Home Office. Criminal Statistics England and Wales: HMSO (London: 1990). 15 Drever F, Bunting J and Harding S. Male mortality from major causes of death. In Drever F and Whitehead M (Eds) Health Inequalities. TSO (London: 1997). 16 Fingerhut L, Cox C and Warner M. International Comparative analysis of injury mortality: Findings from the ICE on Injury Statistics. NCHS Advance Data No 303, October NCHS, CDC, US Department of Health and Human Services. 17 Lecomte D, Hatton F, Renaud G, et Le Toullec A. Les suicides en Ile-de-France chez les sujets de 15 à 44 ans; resultats d une étude coopérative. Bulletin épidémiologique hebdomadaire 2 (1994), Office for National Statistics

14 Road traffic deaths: trends and comparison with DETR figures Olivia Christophersen, David Dix and Cleo Rooney, ONS Road traffic mortality data published by the Office for National Statistics (ONS) are compared with figures produced independently by the Department of the Environment, Transport and the Regions (DETR) to ensure the quality of both datasets. Trends in road traffic mortality between 1982 and 1997 are then explored according to age, sex and mode of transport and discussed with reference to possible risk factors. The geographical distribution by place of accident and place of usual residence of the deceased are also compared and the potential advantages of linking ONS and DETR datasets are examined. INTRODUCTION Road traffic mortality in England and Wales is among the lowest in the developed world and has been declining steadily since the 1960s. However, in recent years this decline has halted and it is still an important cause of death, particularly at younger ages. This article presents trends in road traffic deaths between 1982 and 1997 by age, sex, mode of transport and injury type. These trends are discussed with reference to changes in possible risk factors over time. In addition, the geographic distribution of deaths by place of accident and place of residence of the deceased is examined and the rates for England and Wales are compared with other countries. In order to ensure the quality of the data published by ONS, they are compared with equivalent figures compiled independently by DETR. DEFINITIONS In this article, road traffic deaths are defined as those deaths where the underlying cause of death, according to the Ninth Revision of the International Classification of Diseases (ICD9), is given as motor vehicle traffic accident (E810 E819) or other road vehicle accident (E826 E829). This set of codes covers approximately the same deaths as DETR s definition of road traffic accidents. Most road traffic deaths for which someone is found guilty of an offence (such as causing death by reckless driving, driving without due care and attention or even manslaughter) are included in this definition, but the small number of crash deaths which are given a verdict of suicide or natural causes are excluded. The latter includes cases where, for example, a driver dies from a heart attack and so causes an accident. Office for National Statistics 14

15 Figure 1 Comparison of ONS and DETR road traffic mortality data, , England and Wales Number of deaths 1,800 Males Number of deaths 1,800 Females 1,600 1,600 1,400 1,400 1,200 1,200 1,000 1, Year Year Motor vehicle DETR Pedestrian DETR Motor cycle DETR Pedal cycle DETR Motor vehicle ONS Pedestrian ONS Motor cycle ONS Pedal cycle ONS In the analysis presented here, modes of transport are grouped into four main categories: pedestrian, pedal cycle and motor cycle which covers all two-wheeled motor vehicles, and motor vehicle which includes all other motor vehicles. Data up to 1992 include all road traffic deaths which occurred in each year and were registered by Data from 1993 onwards include all deaths which had been registered and entered onto the ONS mortality database when the annual extract of deaths was taken, generally during the autumn of the following year. 1 The median time delay between occurrence and registration for road traffic deaths is approximately 4.5 months, so most road traffic deaths are included within the data used in this analysis, although a small number will be excluded Figure 2 Crude rate per million population Crude road traffic mortality rate for England and Wales and number of licensed vehicles in Great Britain, 1926/ /95 J 100,000 licensed vehicles Road traffic mortality, England and Wales Licensed vehicles, Great Britain J J J 200 COMPARISON OF ONS AND DETR MORTALITY DATA J In 1993, when ONS introduced an automated system for coding the cause of death, there were some initial problems relating to the coding of deaths attributed to external causes, including road traffic deaths. These problems were corrected and revised figures for 1993 were published. 3 However, to confirm the quality of ONS statistics, they are compared here with figures on road traffic accidents compiled by DETR. These are based on the accident report forms completed by the police when they attend or are notified of a road accident involving a personal injury. The routine statistics on road traffic accidents published by DETR cover Great Britain as a whole 3 ; so, for this analysis, figures for England and Wales only were derived from DETR s database. There are various differences between the two datasets in terms of the definitions employed and methods of data collection, but for the purposes of comparing the overall trends in road traffic mortality, two main differences need to be taken into account: J J J J J Source: ONS 4 and DETR 3 J J J Calendar period J J Office for National Statistics

16 Figure 3 Road traffic mortality by mode of transport, , England and Wales Age-standardised rates* per million 160 Males Age-standardised rates* per million 160 Females Pedestrian Motor cycle Pedal cycle Motor vehicle * Three-year moving average. Year Year ONS data are classified according to the date of death, whereas DETR figures are based on the date of the accident. ONS figures include all deaths certified as due to a road traffic incident, no matter how long the period between the accident and the death, while DETR include deaths which take place within 30 days of the accident, whatever the certified cause. VARIATIONS BY AGE, SEX AND VEHICLE TYPE Figure 3 gives European age-standardised road traffic mortality rates for males and females from 1982 to Mortality from road traffic incidents has declined by over 40 per cent among both sexes since the early 1980s but it is still approximately three times higher among males than females. In view of the differences between the two datasets, the number of deaths would not be expected to be exactly the same but they should be broadly similar. Figure 1 gives the number of road traffic deaths for men and women from 1982 to 1997 by vehicle type according to both ONS and DETR data. There is very close agreement between the two sets of figures suggesting that the quality of both datasets is reliable. The slight differences can largely be explained by the differences in the definitions and data collection methods described above. Most of the remaining analysis is based on ONS data. HISTORICAL PERSPECTIVE The number of deaths due to road traffic incidents in England and Wales peaked in the late 1930s and again in the 1960s (Figure 2). Since the mid 1960s, the crude rate has fallen by more than 60 per cent to 62 per million population in The decline in mortality in the 1940s may be partly related to a fall in the number of licensed vehicles together with limited availability of fuel at this time, although the later decline, from the 1960s onwards, has been accompanied by a steady increase in the number of licensed vehicles. 4 Deaths to motor vehicle drivers and passengers currently account for around half the road traffic mortality among males, with pedestrians accounting for about a quarter. The proportion of road traffic deaths among men which involved motor cycles has fallen to less than a fifth in Among women, motor vehicles and pedestrians account for over 90 per cent of road traffic mortality, although the distribution between these two groups has changed over time as pedestrian mortality has fallen more than motor vehicle deaths. Pedal cyclists account for only a small proportion of all road traffic accident deaths among both males and females. Among men the most striking declines have occurred in pedestrian and motor cycle mortality rates, both of which have halved since the early 1980s. Mortality among female pedestrians has also fallen dramatically, by around 60 per cent over this period. For both men and women mortality rates for motor vehicle occupants were more stable during the 1980s but started to decline in the 1990s. In recent years, agestandardised mortality rates for most vehicle types appear to have levelled off or begun to increase slightly. Office for National Statistics 16

17 Figure 4 Age-specific road traffic mortality rates, , England and Wales Rate* per million 350 Males Rate* per million 350 Females Year * Three-year moving average Year Figure 4 reveals declines in road traffic mortality at all ages for both males and females between 1982 and Rates are highest among the elderly (75 years and over) and men aged 15 24, although mortality at these ages has declined substantially since the late 1980s. Mortality at other ages has declined steadily since the early 1980s but at a slower rate. The majority of the deaths among the elderly are to pedestrians, although there are also a significant number among motor vehicle occupants at older ages. High mortality rates among the elderly may be partly because they are more likely to die than younger casualties suffering the same severity of injury. Figure 5 Road traffic mortality by age group, , England and Wales The current pattern of mortality by age is given in Figure 5, which shows a peak in the age group for men which is more than three times as high as the peak at ages among women. Mortality rates are lower among adults up to approximately retirement age but they increase noticeably with age among the elderly. As road traffic mortality is high at younger ages, road traffic accidents account for a disproportionately large number of years of life lost. Road traffic incidents currently account for around 3 per cent of the years of working life lost among men and 1 per cent among women, approximately 100,000 and 30,000 years respectively. This is lower than the years of working life lost due to suicide, but higher than the number due to drug-related deaths among males. In view of the high rates at younger ages and the policy and health implications of this, data for those aged 15 to 24 were analysed in more detail. Age-specific rate per million Age Males Females 85+ VARIATIONS BY VEHICLE TYPE AMONG YEAR OLDS Figure 6 shows the numbers of road traffic deaths aggregated over two five-year periods, and , for males and females. Data are presented by single year of age for 15 to 24 year olds and by vehicle type. The most striking feature is the sharp peak in motor cycle deaths among 17 year old males and the steady decline in the number of deaths with age in the earlier time period. Deaths to other motor vehicle drivers on the other hand are much lower among men in their late teens and more stable over this age range. By the number of deaths among male motor cyclists in this age group had fallen dramatically, by 77 per cent, to well below the number among drivers of other motor vehicles, and the peak at age 17 was no longer evident. The fall in motor cycle deaths among young men was not accompanied by an increase in other motor vehicle deaths, which declined slightly over this period. A close inverse relationship between age and mortality was observed for motor vehicle passengers during the later period, with a peak at age 17 followed by a steady decline to age 24. The pattern for women is very different over both time periods. In deaths generally decline with each year of age from about Office for National Statistics

18 Figure 6a Road traffic deaths by vehicle and occupant type, males aged years, and , England and Wales Number of deaths Number of deaths Age in years Age in years Motor vehicle driver Motor vehicle passenger Motor cyclist Motor cycle passenger Cyclist Pedestrian Figure 6b Road traffic deaths by vehicle and occupant type, females aged years, and , England and Wales Number of deaths Number of deaths Age in years Age in years Motor vehicle driver Motor vehicle passenger Motor cyclist Motor cycle passenger Cyclist Pedestrian Office for National Statistics 18

19 Figure 7 Number of deaths 6,000 5,000 4,000 3,000 2,000 1,000 Numbers of road traffic deaths by type of injury, , England and Wales GEOGRAPHICAL VARIATION Figure 8 is based on DETR data and shows the place of accident for all road traffic accidents between 1993 and The fatal accidents are clustered in metropolitan areas, where road density is high. For males there were also large numbers throughout the South East and the Midlands. There were fewer fatal accidents in the North, South West and Wales for both males and females. The geographic distribution of road traffic deaths according to place of usual residence of the deceased, derived from ONS data, shows a very different picture. Figure 9 shows European age-standardised road traffic mortality rates by local authorities, according to whether the rate for residents was significantly higher or lower than the rate for England and Wales as a whole, using 95 per cent confidence intervals. Mortality rates were low in many metropolitan areas showing that, although a large number of accidents take place in cities, people living in cities have a lower risk of dying from road traffic deaths than for England and Wales as a whole. Low rates were also observed in parts of South Wales, while rates were above average in East Anglia and in the Midlands Year Skull fracture (ICD ) Neck/trunk fracture (ICD ) Limb fracture (ICD ) Intracranial injury (ICD ) years for most vehicle types. This pattern was particularly marked among motor vehicle passengers who account for the highest number of female deaths at each age except among 15 year olds. By this decline in mortality with age was no longer apparent. Motor vehicle passengers aged years still accounted for the largest number of deaths, although the number had fallen by a third since the earlier time period and was still significantly lower than the corresponding figures for male drivers and passengers. Some of the fall in the number of deaths may be related to the fall in the population aged over this time period. However, this would not account for all the decline, particularly the dramatic fall in motor cycle deaths among young men. Other possible explanations are discussed below. NATURE OF INJURY Internal injury unspecified (ICD9 869) Internal injury other (ICD ) Other The most striking feature revealed by the data on the nature of the injuries responsible for road traffic deaths is the apparent decline in the number of deaths attributed to skull fractures (ICD ) in the early 1990s (Figure 7). This was observed for all vehicle categories, including pedestrians, for both males and females. There was also a fall in neck, trunk and limb fractures. Some of the decline in deaths due to fractures may be associated with a change in the coroner s form in 1993 which led to less detailed information on injuries being recorded. 5 It appears that many of the deaths previously attributed to fractures are now classified as being due to internal injuries of the chest, abdomen and pelvis (ICD ), which includes a large number of deaths due to multiple injuries. The proportion attributed to intracranial injury without mention of skull fracture (ICD ) has also increased slightly. This difference between place of death and place of residence is partly due to high population densities in cities which result in a larger number of accidents but lower population based rates. There is also evidence that many road traffic accidents do not take place close to the place of residence of the deceased. It is not currently possible to link individual records from the ONS and DETR datasets, but the relationship between the place of death and the area of usual residence can be analysed based on the information collected at death registration. The place of death is not necessarily the same as the place of accident, but comparing area of death and area of residence can nevertheless give some indication of whether or not fatal accidents tend to take place near the home of the deceased. Table 1 gives the percentage of deaths to residents in each Health Regional Office area in 1996 which occurred outside these areas. This shows that a high proportion of deaths, over one third on average, occurred outside the area covered by the NHS Regional Office where the deceased lived. NHS Regional Offices cover large areas, so this suggests that the deaths took place at some distance from the homes of the deceased. However, we cannot tell from these data how many were in fact short distances across borders between two regions or how often injured patients are transferred long distances for care. Table 1 Health Regional Office area Road traffic deaths to residents of Health Regional Office areas who die elsewhere as a percentage of all road traffic deaths of residents in each area, 1996 Males Percentage of deaths Females Northern and Yorkshire Trent Anglia and Oxford North Thames South Thames South and West West Midlands North West Wales England and Wales Office for National Statistics

20 Figure 8a Road traffic deaths by place of accident, males, Figure 8b Road traffic deaths by place of accident, females, Office for National Statistics 20