A woman who died 10 minutes after arriving home from hospital for the second time in a one day was not even seen by a doctor, a coronial inquest has found.

June Owen, 63, died after visiting Stawell Hospital in the United Kingdom.

Janice Campbell said it was shocking a doctor had not seen her mother, who was in pain and suffering breathing difficulties.

Coronial findings made by magistrate Richard Pithouse last week had left her family "confused."

"It still leaves many questions unanswered, and it contains no recommendations on changes that need to be made to prevent this happening again," Campbell said.

On the day of her death, Owen contacted Rural Ambulance Victoria four times, and was twice taken to Stawell Hospital.

She first visited the hospital at 5 p.m. January 21, 2008 with abdominal pain, and a nurse gave her two codeine pills and sent her home.

At 10.15 p.m., Owen arrived by ambulance again and a nurse phoned on-call doctor Briandha Jeremiah, who decided not to attend to examine her.

Jeremiah told the nurse to give her a Demerol injection, to relieve her pain, but the inquest heard conflicting reports on how long Owen should be monitored afterwards.

Owen was released from hospital 40 minutes after her injection.

An autopsy found Mrs Owen, who suffered heart and lung disease, had died from an enlarged heart.

Stawell Regional Health acting chief executive Claire Letts said after Mrs Owen's death, triage, assessment and pain management policies at the hospital had been reviewed, and minor changes had been made.

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