The head of the inquiry into the Mid Staffordshire NHS Foundation Trust has insisted that his investigation did not exonerate individuals of blame for the "appalling" suffering of patients caught up in the scandal.
Robert Francis QC said the terms of his inquiry were to examine actions - or inactions - of organisations against a "background of the most appalling" care provided to large numbers of patients at Stafford Hospital.
He said effectively putting people on trial by making one of the inquiry terms of reference that of identifying individuals responsible would have resulted in a number of "unfortunate" results.
"You cannot try people without it being fair," he told MPs on the House of Commons Health Select Committee.
"I personally think that would have had a number of unfortunate results... the first would have been the duration and extent of the inquiry. Every single person involved would have instructed a lawyer, every single person would have to have been a core participant.
"I know some people have criticised the length of my inquiry but I would have been running this inquiry for years - the lessons would not have been learned but perhaps the most important point is that I don't think we would have found out as much as we did."
He added: "I do not believe that this report exonerates people at all, I do urge those who have not done so to read the accounts given of the history in the various chapters about the organisations, where I set out in detail what individuals have done and what they have not done, what letters they got and their reaction to these letters. Others may disagree but I personally believe that is the useful contribution a public inquiry can make in this situation."
Mr Francis's remarks come after relatives of patients called for NHS chief Sir David Nicholson and Royal College of Nursing chief executive Peter Carter to resign over the scandal.
Mr Francis said his job had been to find out from as many people as possible what had happened and to build up a picture of events at Stafford Hospital and then to draw lessons for the future.
"Clearly one of these lessons is that there is insufficient accountability in this system and it is for that reason that I make a number of recommendations in that regard," he said.