Full Breakdown
Awanui Labs Breaches Health Code in Missed Cancer Diagnosis Case
4/20/2026, 9:34:49 PM
Overview of the Incident
Awanui Labs, a pathology service in New Zealand, has been found to have breached the Code of Health and Disability Services Consumers’ Rights following the misdiagnosis of gastric cancer in a woman from Invercargill. The woman, who had been experiencing gastrointestinal bleeding, was misdiagnosed multiple times over an eight-month period, ultimately leading to her death on May 17, 2022.
Sequence of Misdiagnoses
In April 2021, the woman was referred to Southland Hospital after her general practitioner noted black tarry stools. A consultant general surgeon performed a gastroscopy, identifying two gastric ulcers and noting findings suspicious for malignancy. However, the referral to Awanui Labs only mentioned anemia, leading to a biopsy that reported no evidence of malignancy. Subsequent gastroscopies in June and October 2021 yielded similar results, with pathologists failing to recognize the signs of cancer.
In December 2021, after persistent symptoms, a new doctor conducted another gastroscopy, discovering a nodular area that led to a biopsy confirming gastric adenocarcinoma. Awanui Labs later conducted a "hindsight review" and acknowledged that cancer had been present in the earlier biopsies.
Findings from the Health and Disability Commissioner
Deputy Commissioner Vanessa Caldwell concluded that Awanui Labs and the lead gastrointestinal pathologist had failed to provide reasonable care. The review indicated that the clinical information provided during the biopsy requests was inadequate, contributing to the missed diagnoses. Caldwell emphasized that the number of gastroscopies performed should have raised suspicion among the pathologists.
Despite the blind review conducted by six pathologists, only three identified the cancer in the April biopsy. Caldwell noted that the missed opportunities for earlier diagnosis could have allowed for timely chemotherapy.
Official Responses and Recommendations
Awanui Labs accepted the findings and has committed to improving its practices, including requiring pathologists to review endoscopy reports alongside biopsy samples. Dr. Richard Steele, Awanui Labs' chief medical officer, expressed a commitment to enhancing the safety and quality of their services.
Health NZ Te Waipounamu also acknowledged the findings, with Dr. David Gow stating that multiple factors contributed to the tragic outcome and expressing regret for not meeting healthcare standards.
Criticism and Opposition
Critics have pointed out that the systemic failures in communication and information sharing among healthcare providers significantly contributed to the misdiagnosis. The lack of detailed clinical information in biopsy requests was highlighted as a critical issue that needs addressing to prevent similar incidents in the future.
Verbatim Quotes
“I acknowledge that [her] misdiagnosis and subsequent delayed treatment would have had a profound impact on her extended family, and I commend their reasons for wishing to continue with an investigation to ensure that this does not happen to anyone else.” — Deputy Commissioner Vanessa Caldwell
“Our aim is always to provide excellent healthcare, and we deeply regret that in this case we did not meet those high standards.” — Dr. Richard Steele, Chief Medical Officer, Awanui Labs
“Our aim is always to provide excellent healthcare, and we deeply regret that in this case we did not meet those high standards.” — Dr. David Gow, Chief Medical Officer, Health NZ Te Waipounamu
This case underscores the importance of thorough communication and accurate reporting in healthcare to ensure patient safety and timely treatment.
