Manjit Obhrai was appointed Medical Director at Stafford after the crisis came to light. He was brought in partly to look at what had been going wrong.
In an interview with ITV News Central, he spoke about why it went on for so long, without anyone doing anything to stop it.
One thing he blames for the appalling care patients suffered is that no one was accountable.
"If things went wrong...where were they reported to? How were things put right? How were the investigations done? All those systems were fairly random and haphazard. There wasn't the accountability, the visibility of he trust board wasn't there, so the trust board often didn't see what was going wrong. So in a way, the view from the ward to the board was missing.'
Mr Obhrai said one of the first things he did in the role was to conduct a surgical review by the Royal College of Surgeons.
"There were poor outcomes in certain patients with certain aspects of surgery. And there had been two or three deaths the previous year from surgical procedures, which were elective procedures, which was not the norm in the country."
In December 2012, the Health Secretary spoke to ITV News and revealed his concerns about the possibility of problems, like those at Stafford, happening elsewhere.
"What I want to do is understand and learn the lessons. I don't believe this is just an issue that relates to Stafford Hospital. I think it may have happened in its most concentrated form here. But there are lessons that we have to learn for the whole of the NHS."
Mr Obhrai said there is one big complaint at hospitals around the country that relates to basic care - water.
Water is vital for health - and potentially fatal if it is not available. But Mr Obhrai says when he first went to the hospital and did a nightshift, patients were left with just one glass of water to drink for the entire night.
"The jugs were routinely collected with the patient being left one cup of water overnight.
"I saw that first hand and I was absolutely appalled by it.
"They said 'These jugs need washing'. And I think the first thing I said was: 'Go and buy some jugs! These jugs must not be removed overnight.'
"Patient access to water was very poor and I saw it at first hand.
"It was appalling. Why could I not have access to water at 3 o'clock in the morning just because somebody has deemed it appropriate to take my glass away."