Dying alone

The effects on the public health and the broader social impact on communities from lockdowns during the Covid-19 pandemic in 2020–2021 have been widely publicised. A recent study ¹ examined the effect of lockdown in relation to deaths reported to HM Coroner, taking into account the location in which each of the deceased was found and whether or not they were living alone at the time. The authors concluded from their study that perimortem social isolation in lockdown resulted in an increase in people dying at home relative to hospital, and in many cases, their deaths were associated with an increased frequency of advanced decomposition.

The Covid pandemic has since, undoubtedly contributed to changes in social trends and highlighted the problem of isolation from society, whether voluntary or self-inflicted, against a background of a continuing increase in the proportion of persons of all ages living alone for whatever reason. As Health and Social welfare agencies are all too aware, notwithstanding the effects of Covid, one of the consequences of living in a modern society, with the diminution or breakdown of close family ties, lack of adequate support networks as well as an ageing population, especially in affluent countries, is the significant increase in persons living alone and, in many cases in isolation from the rest of the community.

This changing demographic has recently been highlighted by a study analysing data from the Office for National Statistics (ONS), calculating the European Age Standardised Rates for deaths coded as R98 (‘unattended death’) and R99 (‘other ill-defined and unknown causes of mortality’) in the 10th version of the International Classification of Diseases (ICD-10), and the corresponding codes in ICD-9, by sex and age group from 1979 (when ICD-9 began), to 2020. ² The authors regarded these as proxy markers for deaths, where decomposition prevented the finding of a specific cause of death at post-mortem. They also highlighted, that although mortality from all other causes decreased from 1979 to 2020, undefined deaths rose sharply, with more men affected than women. They concluded that the increase in people found dead from unknown causes suggested a breakdown of both formal and informal social support networks. The authors stated that their study had limitations because of the use of undefined deaths as proxy markers for decomposition. However, although the use of unascertained death as a proxy marker for post-mortem decomposition is valid, the absolute number of decomposed bodies would be underestimated, and it has been recommended that a more accurate way of coding decomposed deaths should be employed to inform social health trends. ³

The number of persons who are at risk from dying alone in their own residence and possibly isolated from the community has increased. The ONS ⁴ shows that there were 8.4 million people living alone in the UK in 2023; an increase from 2013 (7.8 million). The number of men living alone in 2023 grew more than the number of women, although overall there continue to be more women living alone. The increase in people living alone was primarily attributed to people aged 65 years and over, who accounted for 93% of the total growth in the number of people living alone. Fifty-nine percent of those aged 65–74 years were women which increased to 68% at 75 years and over.

Coffey in an article in the Independent newspaper ⁵ wrote of a ‘lonely deaths’ epidemic in the UK with thousands of people remaining undiscovered for a week or more. She also highlighted the situation in Japan, where an epidemic of such deaths had been steadily growing, and recognised to the point that it even has its own word, ‘kodokushi’.

A recent article in the Lancet ⁶ reported that nearly 40,000 people died alone at home in Japan in the first half of 2024 and many were undetected for several months, according to the first national analysis of lonely deaths in the country. Although an estimated 40% were found within 24 h, nearly 4000 were discovered more than a month after their death and 130 had lain unnoticed for a year before discovery. Indeed, as the population increases and people live longer, over the next 20 years it is anticipated that the situation in the United Kingdom may show a similar demographic with associated problems as encountered by countries such as Japan and South Korea where those aged 50 and over make up more than half the population.

Living alone frequently equates with isolation and loneliness, although it should be appreciated that the two are not the same and that one may occur without the other. A meta-analytical review of loneliness and isolation as risk factors for mortality ⁷ examined the psychological, behavioural and biological pathways by which social isolation and loneliness lead to poorer health and decreased longevity. The conclusions of the review were in line with a substantial body of evidence showing that individuals lacking social connections (both objective and subjective social isolation) are at risk of premature mortality.

The investigation into the death of persons who have died alone may present difficulties, particularly, as in many cases they are at different stages of decomposition. As we know a substantial number are classed as ill-defined or unascertained deaths although it is acknowledged that the frequency of use of ‘unascertained’ as a cause of death, may vary with the practice of individual pathologists and the need to avoid an inquest when the circumstances point to an obvious natural death. This is particularly the case in elderly persons with a history of multiple co-morbidities. However, one cannot underestimate the possibility of an unnatural death occurring and the need for a thorough investigation of all the circumstances of the discovery, the location, identity and medical history if available; then followed by a complete and comprehensive post-mortem examination.

Dying alone, especially when isolated and lonely (whether objective or subjective) is a tragedy that needs urgent attention. It is essential for us to learn from the experience of Japan and other affluent countries and act as a matter of urgency. It is incumbent on us to ensure that Public Health agencies, Age UK and other allied charities, social services and other support networks have adequate resources made available to them so that they can address the physical and mental well-being of vulnerable persons living on their own.