The Deputy Health and Disability Commissioner has found Awanui Labs breached the Code of Rights after two biopsy readings in 2021 failed to detect stomach cancer, delaying treatment for a 74-year-old woman who later died.

In a decision released today, Deputy Commissioner Vanessa Caldwell found Awanui Labs breached Right 4(1) — the right to services of reasonable care and skill — for missed opportunities in April and October 2021 to identify gastric adenocarcinoma. The lab’s lead gastrointestinal pathologist, referred to as Dr G, was also found in breach for his role providing a second opinion on the October slides. Other clinicians received adverse comment but were not found in breach.

The woman, anonymised as Mrs A, was referred to Southland Hospital in April 2021 with anaemia and suspected gastrointestinal bleeding. Across that year she underwent four gastroscopies. Biopsies in April, June and October were reported as showing no malignancy. A December 24 biopsy confirmed gastric adenocarcinoma. A “hindsight review” then identified cancer in the earlier April and October samples.

An ACC-arranged blind review by a panel of histopathologists concluded the April cancer signals were extremely subtle and might reasonably have been missed at the time. However, reviewers said the October biopsy should not have been reported as negative.

Awanui Labs acknowledged diagnostic errors in May and October 2021. It said the May sample contained a very limited amount of poorly differentiated cancer that was difficult to recognise, and that the October diagnosis was influenced by limited clinical details on the request forms and the two prior negative results. The lab highlighted that, unlike other regions, endoscopy reports were not routinely provided with Southern requests, and said pathologists rely heavily on complete clinical context.

Health NZ Southern accepted context helps, but pushed back on the suggestion that brief request forms were a root cause, saying biopsies should be examined with the same rigour regardless of how the form is filled out. It also said it would not ordinarily refer cases to a multidisciplinary meeting (MDM) when histology is reported as non-cancerous.

The surgeon who performed the April, June and October endoscopies, Dr C, recorded ulcers “suspicious for malignancy” in April but listed only “anaemia” on the laboratory request. Independent advice to HDC from surgeon and endoscopist Dr Linus Wu found moderate and mild departures from expected practice in the clinical information supplied on April, June and October forms, and said Dr C should have pursued a pathology review or MDM discussion when endoscopic impressions and histology did not align. The Deputy Commissioner issued adverse comment about Dr C’s communication and escalation but did not find him in breach, noting the April biopsy changes were particularly difficult to identify.

Pathologists involved in the case — Drs D, F and G — apologised to the family. Dr D’s April and December reporting was reviewed with adverse comment but no breach, informed by the ACC panel’s view that the April changes were exceptionally subtle. Dr F received adverse comment for the October misdiagnosis but had sought a second opinion from Dr G; as the senior pathologist, Dr G was found responsible for the October error and in breach.

Mrs A was prioritised for treatment after the December diagnosis but died on 17 May 2022.

Since the event:

• Awanui Labs says pathologists must now check Health Connect South for the endoscopy report when reporting gastrointestinal biopsies. It will develop training on the importance of detailed clinical information accompanying samples and implement a policy clarifying when to seek second opinions or further tissue.
• Dr D has added routine second-reads before releasing reports, audits of prior cases, targeted education, and a lower threshold to seek colleague review.
• Dr F has completed additional gastrointestinal pathology training, audited her cases and adopted a lower threshold for immunohistochemical staining in gastric ulceration.
• Dr G has undertaken further education and emphasised a low threshold for cytokeratin staining in ulcerating gastric lesions.
• Dr C now attaches printed endoscopy reports to histology requests and says he will more readily seek MDM review and input from upper GI oncology colleagues.

The Deputy Commissioner recommended written apologies from Awanui Labs and the pathologists, education and policy changes at the lab, and that Health NZ Southern change its processes so endoscopy reports accompany all gastrointestinal histology requests. She also urged stronger communication between pathology and surgery, MDM review of discordant findings, and seeking second opinions when clinical and laboratory signals don’t match.

Sections of the report relating to the clinicians will be sent to the Medical Council. An anonymised version will be published on the HDC website and shared with relevant agencies for education.