Stewart, 30, was travelling in the coach with Almus Ali, an Egyptian man, from Appin to Wollongong.

On the evening of May 4, Stewart suffered a giddy attack and fell on the pole between the two horses. One of the horses kicked his body.

Ali and another companion returned Stewart to the coach and packed him between mailbags to keep him steady before travelling for help.

They reached the Albert Memorial Hospital about 2.30am but were refused admittance by the matron, Mrs Sarah Nichols.

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Nichols told the inquest she had asked Ali whether Stewart's injuries were serious. He said they were not, so suggested they seek medical advice in the morning. She said she had a seriously ill patient, who had just been administered a sleeping draught and she did not want to disturb him.

Ali countered that the matron said Stewart could not be admitted without a permission slip from a doctor. This was in contravention of the hospital rules, which stated no accident case could be turned away.

What followed was a tragic journey as Stewart was carted about the town for the next three hours in a search for assistance.

First stop was the Wollongong Post Office, where he was taken off the coach so that the mail could be unloaded. He was then lifted back into the cart and taken to the Harp Inn, where he was refused entry. Then followed a trip to the home of Dr William Thomas, who was out on a call; Mr Hoskings, the chemist, who said he could do nothing; then a hotel in Upper Crown Street and a lodging house in Market Square, where he was refused admittance. With his options exhausted, Ali drove Stewart to Wollongong police station where the constabulary assisted his admission to hospital. Later that morning, Stewart saw Dr Thomas, who determined that his neck had been broken and his spine fractured in two places.

He died later that evening.

In the wake of the case, matron Nichols, who had previously refused admission to another patient, was reprimanded by the hospital committee.