Key Takeaways
- A retired nurse suffered recurrent gastrointestinal bleeding for eight months before stomach cancer was finally detected on a Christmas‑eve gastroscopy in 2021.
- Initial biopsies taken in April, June and October 2021 were reported as benign, but a later “hindsight review” revealed gastric adenocarcinoma was present in the April and October samples.
- The Deputy Health and Disability Commissioner found that Awanui Labs and its lead gastrointestinal pathologist breached the Code of Health and Disability Services Consumers’ Rights by failing to exercise reasonable care and skill.
- Expert review indicated the cancerous changes were extremely subtle; only three of six pathologists would have identified the malignancy in the April biopsy without hindsight.
- Recommendations focus on improving clinical information transfer, standardising pathology review processes, and providing additional training to prevent similar diagnostic delays.
Case Overview
The case involves a retired nurse from Invercargill who presented to Southland Hospital in 2021 with persistent black‑tarry stools, a sign of recurrent gastrointestinal (GI) bleeding. After referral by her GP, she underwent a series of gastroscopies over eight months. Despite multiple biopsies, pathology reports repeatedly returned negative for malignancy, delaying a definitive diagnosis until a fourth procedure on Christmas Eve 2021 revealed gastric adenocarcinoma. The patient commenced prioritized treatment in early 2022 but succumbed to the disease on 17 May 2022.
Eight‑Month Diagnostic Delay
From April to December 2021 the patient experienced ongoing GI bleeding and anemia, yet each endoscopic evaluation failed to raise sufficient suspicion for cancer. The first gastroscopy on 30 April 2021 identified two gastric ulcers with surrounding inflammation, noted as “suspicious for malignancy,” but the referral to the laboratory listed only anemia, omitting the endoscopic concern. Subsequent scopes in June and October similarly reported ulceration and inflammation without a malignancy work‑up, contributing to the prolonged interval before cancer was identified.
First Gastroscopy and Initial Biopsy
During the April 2021 gastroscopy, the consultant general surgeon observed anemia, two gastric ulcers, and two large ulcers with surrounding inflammation, documenting the findings as suspicious for malignancy. However, the histology request sent to Southern Community Laboratories Limited (later Awanui Labs) listed only anemia as the clinical detail. A consultant pathologist examined the biopsies on 5 May 2021 and reported no evidence of metaplasia, dysplasia, or malignancy, prompting no second opinion. The limited clinical information likely hindered the pathologist’s ability to focus on subtle neoplastic changes.
Second Gastroscopy and Repeat Negative Biopsy
In June 2021 the patient returned for a follow‑up gastroscopy performed by the same surgeon. The referral form again listed only “gastric ulcer” as the clinical detail, omitting the earlier suspicion of malignancy. The same pathologist reviewed the new biopsies and, once again, found no metaplasia, dysplasia, or malignancy. No second opinion was sought, and the patient continued to be managed for anemia and ulcer disease rather than being investigated for a possible neoplastic process.
Third Gastroscopy Before Diagnosis
By October 2021 the patient was admitted to Southland Hospital’s Day Surgery Unit with symptomatic iron‑deficiency anemia while on rivaroxaban, though overt GI bleeding was absent. A new consultant general and renal physician performed another gastroscopy, noting localized severe inflammation and ulcerations in the gastric body. The referral to Awanui Labs cited “upper GI bleeding.” An anatomical pathologist, with review by a consultant pathologist, reported no evidence of metaplasia, dysplasia, or malignancy. Despite the evolving clinical picture, the pathology reports remained negative, representing another missed opportunity for early cancer detection.
Final Gastroscopy and Cancer Discovery
Concerning symptoms persisted, leading to a fourth gastroscopy on Christmas Eve 2021 performed by a physician who had not previously treated the patient. The endoscopist observed a 30 mm nodular area of markedly inflamed mucosa surrounding a partially healed ulcer scar. Biopsy taken from this lesion was examined by the original pathologist, who this time identified gastric adenocarcinoma. Following this positive result, Awanui Labs conducted a routine hindsight review of the earlier three biopsies and discovered that malignant cells had been present in the April and October 2021 specimens, confirming that the cancer had been missed twice before.
HDC Review and Expert Opinions
The Deputy Health and Disability Commissioner commissioned a blind review of the April, June and October biopsy slides by a panel of five histopathologists. The experts concluded that the malignant changes in the April biopsy were “extremely subtle” and only appreciable with the benefit of hindsight from later specimens. One panelist noted that the October slides contained changes highly suspicious for malignancy that had been overlooked. An oncologist opined that a two‑month delay in diagnosis—spanning the period between the missed October biopsy and the Christmas‑eve detection—resulted in clinically meaningful tumor growth in this patient’s case, adversely affecting her outcome due to the aggressive nature of her gastric cancer.
Impact of Diagnostic Delay on Outcome
The oncologist’s assessment emphasized that while a two‑month delay might not be consequential in typical gastric cancer presentations, it was significant here because the patient’s tumour exhibited rapid progression. The delay deprived her of the chance to initiate chemotherapy earlier, potentially altering disease trajectory and survival. This viewpoint underpinned the Commissioner’s concern that the missed diagnoses constituted a serious breach of the duty of care owed to the patient.
Awanui Labs Acknowledgement and Pathologist Statements
In response to the HDC investigation, Awanui Labs admitted diagnostic errors in the May (April biopsy) and October 2021 reports. The laboratory conceded that the May diagnosis missed a subtle area of cancer and that identifying small amounts of poorly differentiated gastric adenocarcinoma is inherently challenging. Regarding the October misdiagnosis, Awanui Labs explained that the clinical information supplied did not raise a high suspicion of cancer, and the pathologists’ judgment was colored by the two prior negative biopsies. All involved pathologists acknowledged that they had missed the gastric adenocarcinoma in their initial reports.
Deputy Commissioner’s Findings and Code Breach
Deputy Commissioner Vanessa Caldwell determined that both Awanui Labs and its lead gastrointestinal pathologist violated the Code of Health and Disability Services Consumers’ Rights. She held 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 the biopsy specimens accurately. The Commissioner stressed that, given the volume of gastroscopies requested between April and December 2021, the laboratory should have heightened suspicion and instituted safeguards to catch subtle malignancies.
Blind Review Results and Pathologist Consensus
The blind review revealed that only three of the six pathologists would have identified gastric adenocarcinoma in the April 2021 biopsy without hindsight, underscoring the lesion’s subtlety. Nevertheless, every pathologist involved conceded that they had missed the malignancy in both the April and October specimens during their original reporting. This collective admission highlighted missed opportunities for earlier therapeutic intervention and reinforced the need for systemic improvements in histopathology practice.
Recommendations and Organisational Responses
Caldwell recommended that Awanui Labs develop education and training programmes stressing the necessity of providing detailed, relevant clinical information—including endoscopy reports—with histology requests. She also urged the implementation of a clear policy or protocol for pathologists to follow when reviewing histology cases, ensuring that diagnostic options are explicitly considered. Health NZ Southern was advised to modify its gastrointestinal histology request process to automatically attach a copy of the endoscopy report, thereby furnishing pathologists with a more complete clinical picture.
In response, Awanui Labs’ chief medical officer, Dr. Richard Steele, accepted the recommendations, citing steps already taken: requiring pathologists to review endoscopy information alongside biopsies, reinforcing the importance of complete clinical data, and delivering additional training to teams. Health NZ Te Waipounamu’s chief medical officer, Dr. David Gow, echoed the acceptance, noting that the organisation has implemented significant changes to align with the Commissioner’s guidance and will continue collaborating with Awanui Labs and clinicians to prevent recurrence of such diagnostic failures. The case serves as a stark reminder of how subtle pathological findings, incomplete clinical communication, and systemic lapses can converge to delay cancer diagnosis with tragic consequences.