Key Takeaways
- The woman experienced recurrent gastrointestinal bleeding in 2021 but was not diagnosed with gastric adenocarcinoma until December, after four gastroscopies and multiple pathology reports.
- Initial pathology reports in April and October 2021 failed to detect subtle cancer cells, a miss later confirmed by a hindsight review.
- Inadequate clinical information on histology request forms contributed to pathologists’ difficulty in recognizing malignancy.
- The Health and Disability Commissioner (HDC) found Awanui Labs and the lead gastrointestinal pathologist breached the Code of Health and Disability Services Consumers’ Rights.
- Expert opinion indicated that a two‑month delay in diagnosis allowed clinically meaningful growth of an aggressive tumor, negatively affecting the woman’s outcome.
- All involved clinicians and the laboratory apologized to the family; Awanui Labs accepted the HDC’s recommendations and instituted systemic changes.
- Recommendations include mandatory attachment of endoscopy reports to histology requests, enhanced pathologist training, and clearer reporting protocols to prevent future missed diagnoses.
- Health NZ Southern and Awanui Labs have pledged to implement the commissioner’s recommendations and improve communication between endoscopy and pathology services.
Background and Initial Presentation
In 2021 the woman was referred to Southland Hospital by her local GP after presenting with black, tarry stools indicative of recurrent gastrointestinal (GI) bleeding. She was seen by a consultant general surgeon who performed a gastroscopy on 30 April 2021. The surgeon’s notes described anemia, two gastric ulcers, two large ulcers with surrounding inflammation, and noted the findings were “suspicious for malignancy” with “oozing gastric ulcers.” Despite these concerning observations, the referral sent to Southern Community Laboratories Limited (now Awanui Labs) listed only anemia as the clinical detail, omitting the endoscopic findings that raised suspicion of cancer.
First Gastroscopy and Missed Diagnosis
Biopsy specimens from the April gastroscopy were examined by a consultant pathologist who reported on 5 May 2021 that there was no evidence of metaplasia, dysplasia, or malignancy. Because the result was benign, no second opinion was sought. A subsequent CT scan of the chest, abdomen, and pelvis showed no cancer but identified a left atrial appendage thrombus. The woman proceeded to a second gastroscopy in June, again performed by the same surgeon; the histology request noted only “gastric ulcer,” and the pathologist once more reported no malignant changes. These early misses meant that a cancer that was already present remained undetected despite multiple endoscopic evaluations.
Subsequent Procedures and Continued Oversight
In October the woman was admitted to Southland Hospital’s Day Surgery Unit with symptomatic iron‑deficiency anemia while on rivaroxaban. A new consultant general and renal physician ordered another gastroscopy, which the original surgeon performed. He observed localized severe inflammation and ulcerations in the gastric body and stomach, and the referral form to Awanui Labs cited “upper GI bleeding.” The biopsy again returned negative for metaplasia, dysplasia, or malignancy. By late December, persisting symptoms prompted a Christmas‑eve gastroscopy performed by a physician who had not previously treated the woman. This endoscopy revealed a 30 mm nodular area of markedly inflamed mucosa around a partially healed ulcer scar. Biopsy from this lesion finally identified gastric adenocarcinoma.
Role of Pathology and Clinical Information Gaps
A critical factor in the delayed diagnosis was the limited clinical information accompanying each histology request. The initial April and October referral forms omitted key endoscopic details such as ulcer size, inflammation, and the surgeon’s suspicion of malignancy. When the pathology laboratory later conducted a hindsight review of the original three biopsies (April, June, and October), it confirmed that gastric adenocarcinoma had been present in both the April and October specimens, but the subtle malignant cells were missed in the initial reports. The pathologists acknowledged that, without the endoscopic context, distinguishing early malignant cells from benign inflammatory changes was exceedingly difficult.
HDC Investigation Findings and Expert Opinions
The Health and Disability Commissioner commissioned a blind review of the stained biopsy slides from April, June, and October by a panel of five histopathologists. The review concluded that the changes in the April biopsy were “extremely subtle” and only discernible with the benefit of hindsight from later biopsies. One pathologist noted a failure to recognize the serious changes in the October slides, which were highly suspicious for malignancy. An oncologist consulted by the HDC opined that a two‑month delay in diagnosis allowed clinically meaningful growth of an aggressive tumor in this specific case, adversely affecting the woman’s prognosis, although such a delay might not be consequential in typical gastric cancers.
Systemic Failures and Code Breach Determination
Deputy Commissioner Vanessa Caldwell determined that Awanui Labs and the lead gastrointestinal pathologist breached the Code of Health and Disability Services Consumers’ Rights. The Commissioner found that Awanui Labs failed to provide services with reasonable care and skill on two occasions—April and October 2021—by not ensuring that its pathologists reported on the biopsy specimens appropriately. Given the number of gastroscopies requested between April and December 2021, the Commissioner argued that the repeated testing should have heightened suspicion among those interpreting the biopsies. The lack of sufficient clinical information on histology request forms was identified as a contributing factor to the missed diagnosis.
Recommendations and Institutional Responses
In response to the breach, the HDC issued several recommendations: Awanui Labs must develop education and training emphasizing the need to attach detailed endoscopy reports to histology requests; implement a policy or protocol guiding pathologists on how to consider all diagnostic options when reviewing histology cases; and ensure that the original surgeon provides gastroscopy reports with histology submissions. Health NZ Southern was advised to change its process for all gastrointestinal histology requests to automatically include a copy of the endoscopy report, thereby giving pathologists a more complete clinical picture.
Impact and Reflections from Stakeholders
All doctors and pathologists involved apologized to the woman’s family for the missed diagnosis and its tragic outcome. Awanui Labs’ chief medical officer, Dr Richard Steele, accepted the Commissioner’s findings, stating that the laboratory had already begun reinforcing the importance of complete clinical information, providing additional training, and requiring pathologists to review endoscopy information alongside biopsy samples. Health NZ Te Waipounamu’s chief medical officer, Dr David Gow, echoed these sentiments, acknowledging that the case revealed multiple organisational shortcomings and pledging continued collaboration with Awanui Labs to prevent similar incidents. The woman, described prior to her illness as being in “excellent health of body and mind” and a retired nurse and caregiver for her husband, ultimately succumbed to the disease on 17 May 2022, underscoring the profound human cost of diagnostic delays.