Summary
Beatrice Fraenkel is an ergonomist and non-executive director at Stockport NHS Foundation Trust. In this blog, Beatrice shares her reflections on the approach taken to establish a just culture at Mersey Care NHS Foundation Trust during her 14 years as Chair of the organisation. She explores the relationship between culture, leadership, and patient safety, and how one organisation’s journey shows both the power of getting it right and the risks when it begins to unravel. This draws on a presentation Beatrice gave at the Royal Society of Medicine Psychological Safety Conference on 9 June 2026.
Content
There is a well-established truth in healthcare: staff morale and the safety of patients are inseparable.
When staff feel safe, supported and able to speak openly, patients are safer.
When staff feel fear, blame or futility, harm follows.
Mersey Care understood this early.
Its journey over the past decade illustrates both the remarkable benefits of investing in culture and the consequences when that culture begins to erode.
Building a just and learning culture
From 2014 onwards, at Mersey Care NHS Foundation Trust we made a deliberate strategic decision to embed a just and learning culture across the organisation.
This wasn’t a slogan. It was a strategic investment. We sought to move towards a truly restorative just culture that touched on many different aspects of the organisation: leadership development, human resources, disciplinary processes, psychological safety, partnership working, and open and honest reporting.
The results were profound. Between 2016 and 2021, Mersey Care achieved:
95% reduction in suspensions (between 2014-2020)[1]
85% reduction in investigations (between 2014-2020)[1]
£1.7-2.5m in economic benefit[[1]
higher staff morale[2]
higher incident reporting
fewer repeat harms
faster learning cycles.
This was not about being ‘soft’. It was about building the conditions for safe care—and it worked.
A major test: integrating Liverpool Community Health
The true strength of any culture is tested during periods of change.
In 2018, Mersey Care acquired Liverpool Community Health NHS Trust, an organisation that had experienced one of the most serious cultural collapses in the NHS.
An independent review described an organisation characterised by bullying, fear, suppression of incident reporting, retaliation against staff who spoke up, unsafe staffing levels and leadership that was “out of its depth”.[3]
The staff who transferred into Mersey Care were traumatised. They came from an environment where speaking up was dangerous.
Mersey Care had a choice—absorb these staff and hope for the best or actively use its just and learning culture to rebuild trust and safety.
The Trust chose the second path and invested heavily in:
restorative conversations
psychological safety training
visible leadership
transparent reporting
rebuilding team identity.
Many of the staff transferring into Mersey Care arrived having experienced years of organisational trauma. Speaking up had previously carried personal risk, and rebuilding trust would require far more than structural integration.
Rather than simply absorbing these teams into existing services, Mersey Care invested in restorative conversations, psychological safety training, visible leadership, transparent reporting and rebuilding team identity.
Between 2018 and 2022, the impact was reflected in organisational measures:
Incident reporting increased without a corresponding increase in harm.
Repeat harms reduced.
Staff engagement improved.
Governance strengthened.
The integration of Liverpool Community Health didn’t derail Mersey Care’s culture journey—it validated it.
When leadership changes, culture changes
Culture, however, is fragile and leadership behaviour is its most powerful determinant.
In 2023, Mersey Care experienced a significant leadership change in the appointment of its new chair who had a very different approach, philosophy and personal style.
Many staff reported experiencing changes in leadership style, organisational tone and psychological safety.
Initially, the organisation's safety indicators remained stable. Incident reporting stayed high, mortality measures remained steady and there was no immediate increase in patient harm.
This reflected the resilience that had been built over the previous decade.
However, beneath these headline indicators, staff described a different experience. Reports emerged of declining psychological safety, reduced morale, increasing concern about repercussions for speaking openly and a slowing of organisational learning.
Several key people—individuals who had been cultural anchors—left the organisation.
The board became less of a champion and driving force for an open and fair culture, with many reflecting that the leadership centre of gravity had become destabilised.
Some employees expressed concern that the organisation felt increasingly similar to the environment experienced previously within Liverpool Community Health, with comments such as, "We've been here before" and "This feels like Liverpool Community again."
The cultural deterioration was now visible not only to staff, but to partners, regulators and system leaders.
Recognising the risks before harm appears
One of the most important lessons from patient safety research is that deterioration in culture often becomes evident long before patient harm appears in routine performance data.
In the case of Mersey Care, staff raising concerns with the executive team had recognised that harm to staff had reached a point close to causing patient harm. A conversation was initially held with the Integrated Care Board, who offered support but not action, and so these issues were taken to NHS England.
In June 2025, NHS England commissioned an independent review into culture and working relationships at Mersey Care.
Although the contents of that review remain private, the decision to commission an independent review indicates that concerns about organisational culture and risk were considered sufficiently significant to warrant external examination.[4]
This is exactly the pattern described in a previous Bill Kirkup report into Liverpool Community Health: cultural decline, leadership fracture, fear, defensiveness and the slow erosion of learning—all long before harm appears in the data.[5]
The resilience built between 2014 and 2022 held the safety system together. It prevented immediate harm. But harm was still created—in staff wellbeing, trust, psychological safety and the organisation’s ability to learn. And the potential for future harm increased.
5 lessons for every healthcare organisation
Mersey Care's experience offers important lessons that extend well beyond a single NHS Trust:
Culture is not a project. It is a strategic asset that requires constant leadership attention.
Psychological safety is not optional. It is the foundation of safe care.
Restorative practice works. It stabilised traumatised teams, rebuilt trust and delivered measurable improvements.
Leadership matters more than any policy. A single shift in leadership behaviour can undo years of cultural progress.
Board cohesion is not a governance technicality; it is a patient safety issue. When boards fracture, organisations fracture.
Perhaps, most importantly, resilience is built during periods of stability not during crisis.
Today, Mersey Care is focusing on rebuilding trust, restoring respectful relationships and strengthening partnerships across the wider health and care system. That work acknowledges an important reality: repairing culture takes considerably longer than damaging it.
References
1. NHS Employer. Implementing a Just and Learning Culture: Mersey Care NHS Foundation Trust. October 2020. https://shbn.org.uk/wp-content/uploads/2021/03/Just-culture-Mersey-case-study.pdf
2. Mersey Care NHS Foundation Trust. Quality Report 2023/24. July 2024. https://merseycare-nhs-ft.gs-microsites.net/wp-content/uploads/sites/233/2025/02/Quality_Report_2023-24_july_2024.pdf
3. Dr Bill Kirkup CBE. Report of the Liverpool Community Health Independent Review. January 2018. https://www.england.nhs.uk/wp-content/uploads/2019/09/LiverpoolCommunityHealth_IndependentReviewReport_V2.pdf,
4. Tidman Z. ‘Divisive and toxic’ culture found at trust. Health Service Journal, 27 July 2026. https://www.hsj.co.uk/mersey-care-nhs-foundation-trust/exclusive-divisive-and-toxic-culture-found-at-trust/8123893.article
5. Dr Bill Kirkup CBE. Report of the Liverpool Community Health Independent Review. January 2018. https://www.england.nhs.uk/wp-content/uploads/2019/09/LiverpoolCommunityHealth_IndependentReviewReport_V2.pdf
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About the author
Beatrice is an ergonomist and industrial design engineer with a long record of working across a number of sectors to help improve outcomes for users while improving quality and user satisfaction without increasing costs.
Among other things, Beatrice has chaired an NHS primary care trust, The Architects Registration Board and a regional regeneration body. She recently completed 14 years as Chair of Mersey Care NHS Foundation Trust. She is currently a non-executive director at Stockport NHS Foundation Trust where she chairs the People Committee. Beatrice also sits on other boards connected with health, regeneration and economic growth and is a trustee of Design in Mental Health. Beatrice holds an Honorary Fellowship of the Royal Institute of British Architects and is an Honorary Alderwoman of the City of Liverpool.
Beatrice is passionate about learning and believes openness and transparency is a key aspect of this. She is delighted to bring her background as an ergonomist and her other experiences to be involved in patient safety and learning from mistakes within a no blame culture.
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