Seven adults and four children were killed and 23 other people injured, when a truck crashed into a V/Line passenger train at a level crossing just north of the northern Victorian town on June 5, 2007.

The truck driver, Christiaan Scholl, was acquitted of 11 charges of culpable driving and eight counts of negligently causing serious injury by a Supreme Court jury in 2009.

The inquest into the deaths began in 2011 and heard from witnesses including the train driver, conductors, police, witnesses, paramedics, doctors and crash survivors.

Coroner Jane Hendtlass on Monday outlined 25 recommendations in her findings, including calls for transport authorities to improve infrastructure and warning systems at the state’s level crossings, for emergency services to work better together and for regional trains to be fitted with first aid equipment and tools for removing seats in the event of another crash.

But the families of some victims said they were expecting more from the recommendations, which came from the 2011 inquest.

Dot Stubbs, whose son Matthew, 13, was among those killed, said it was hard not having someone accept responsibility for the disaster.

‘‘It’s just like it happened yesterday ... we don’t feel like we’ve achieved anything, we don’t feel like anyone’s put their hand up and said they’re to blame. Who’s to blame? Someone has to be to blame but who is it.

Julie McMonnies, whose husband, Geoff, 50, and daughter, Rosanne, 17, were among the victims, said she was expecting more from the findings in the hope ‘‘that other families don’t have to go through what we’ve been through’’.

‘‘I was hoping for a little bit more from the coroner’s report,’’ said Mrs McMonnies, whose daughter Sharise was also injured in the crash.

‘‘I [haven’t had] any satisfaction yet from any investigation that has taken place and I don’t think that we’re going to find any satisfaction here because we still have so many questions that are unanswered.’’

The inquest was told the level crossing was notoriously unsafe, and had been involved in five near misses the year before the crash.

Some passengers told the inquest ambulance crews were slow to arrive to the scene and that the injured were left too long without medical attention, although emergency services rejected those claims. Rural doctors were also angry at being turned away from the disaster scene.

Mr Scholl told his trial he had checked the warning lights when he was about 300 metres from the crossing and considered it safe to proceed because they were not flashing.

He continued driving at 100km/h but hit the brakes when he saw traffic slowing and the train coming, just seconds before the collision.

Adrienne Rowell, a passenger on the train, acknowledged some changes had been made to emergency services since the tragedy, such as Victoria’s rural ambulance service becoming part of Ambulance Victoria.

But she was critical of the time it took paramedics to treat the injured.

‘‘We had people bleeding and we had people dying but they wouldn’t let the doctors in because of this so-called emergency thing that you can’t come in unless you were wearing an emergency vest,’’ Ms Rowell said.

‘‘How does that stop people from dying? How does that stop people from getting help? All we want to see is the changes so that doesn’t happen to anyone else.’’

Jodie Burford, a conductor who gave evidence at the inquest, said the train was ill-equipped to deal with such a disaster. She recalled people using serviettes, curtains and bottled drinking water to treat the injured while they waited for emergency services.

Detective Leading Senior Constable Trevor Collins, from Victoria Police’s major collision investigation unit, acknowledged emergency services agencies needed to work better, although some improvements had already been implemented.

‘‘I think communication was the biggest problem and that’s been addressed,’’ he said.

‘‘If everybody takes on board what the coroner said today, lessons out of these types of incidents have to be learnt, and have to be acted upon.’’

Also killed in the collision were Stephanie Meredith, 46, and her daughters, Danielle, 8, and Chantal, 5, Jean Webb, 79, Margaret Wishart, 78, Harold Long, 83, Nicholas Parker, 32, and Jaeseok Lee, 26; and Matthew Stubbs, 13.

The 11 deaths from the Kerang crash were included in a wider inquest that investigated the deaths of 26 people at Victorian level crossings.