Methodology pages

Methodology

How concerns become recurring issues

PFD Monitor extracts each individual concern a coroner raised within their report. It then uses AI to look for concerns in other reports that describe the same underlying safety problem.

When the evidence supports a match, concerns from different reports can be brought together as a recurring issue. Every concern remains linked to the coroner's original words, so you can inspect the evidence for yourself.

We begin with the coroner's words

Some reports raise one concern. Others raise several. PFD Monitor records each individual concern separately where the report supports doing so.

For each concern, PFD Monitor keeps the original wording, its location in the report, and a shorter description that helps with searching and comparison. The shorter description must not add a cause, responsibility, or recommendation that the coroner did not state.

Quality check
The original wording is kept separately from PFD Monitor's description and recurring-issue link. Correcting our analysis never changes the coroner's words.

AI compares the underlying problem

Two concerns can be linked when one accurate description of the safety problem fits both without hiding an important difference.

The AI considers what was missing, unsafe, delayed, or not done. It also looks at what the problem affected and whether details such as timing, setting, or the people affected are essential to its meaning.

Not every difference matters. Reports may name different people, places, or organisations but still describe the same underlying problem. Equally, concerns on the same broad subject may describe different problems and remain separate.

Example
Two reports might both say that important risk information was not passed between services. They could belong to the same recurring issue even if the services were different. A concern that staff were not trained to recognise the risk remains separate: it describes a training problem, not a failure to share information.

Finding a possible match is not the final decision

PFD Monitor searches its existing list of recurring issues for plausible matches. It then examines the strongest possibilities more closely.

There are four possible outcomes:

  • Matched: the concern fits one existing recurring issue.
  • No match: none of the existing issues fits closely enough.
  • Ambiguous: more than one issue may fit, but there is no clear choice.
  • Not enough evidence: the report does not support a reliable decision.

Similar wording or a high similarity score may help the AI find possible matches, but neither is enough to confirm one.

PFD Monitor leaves a concern unmatched rather than forcing it into the wrong issue. Unmatched and unclear concerns remain available on their report pages and can be considered again in a later update.

Technical note
The AI creates a compact analytical description of each concern to help it find and compare possible matches. Each decision is tied to a version of the method and the recurring-issue list. Exact prompts, thresholds, software, and testing materials are proprietary.

When is an issue recurring?

An issue is published as recurring only when it appears in more than one distinct Prevention of Future Deaths report.

Once published, the issue keeps the same identity as new reports are added. It can still be corrected, split, merged, or retired if new evidence changes its boundary.

Some issues may also be labelled Emerging, Frequently reported, or Dormant. These labels describe patterns in the reports available to PFD Monitor. They do not measure how common or severe a problem is in the wider world. Dormant does not mean resolved.

A recurring-issue page brings together concerns that PFD Monitor has judged to describe the same underlying safety problem. It helps readers discover related reports and compare what coroners wrote.

The link does not mean that:

  • the deaths had the same cause or circumstances;
  • a report recipient caused or was responsible for a concern;
  • an earlier response or action failed; or
  • the reports prove legal responsibility or non-compliance.

If a later report names the same organisation and contains the same recurring issue, PFD Monitor may call it a potential recurrence. This is an invitation to inspect the evidence, not a conclusion about what happened between the reports.

Interpret with care
AI judgements can be wrong, particularly when a report is complex or unclear. PFD Monitor keeps the source words visible, records uncertainty, checks its outputs, and allows decisions to be corrected in later versions.

Corrections and feedback

If you believe a concern has been extracted incorrectly or linked to the wrong recurring issue, send us the PFD Monitor page, the relevant source passage, and an explanation of the problem.