Beauty clinic breaches Code for poor care standards, Deputy Health and Disability Commissioner finds - 21HDC02297

A woman’s rights under the Code of Health and Disability Services Consumers’ Rights were breached by a beauty clinic said the Deputy Health and Disability Commissioner in a decision released today.

Dr Vanessa Caldwell found the woman had experienced significant harm from a thermal shock lipolysis (TSL) treatment. During the final stage of the treatment, the TSL machine overheated, causing a severe third-degree burn on the woman’s abdomen. This injury required a skin graft and resulted in a week-long hospital stay.

Dr Caldwell’s investigation identified several systemic issues that contributed to the incident, noting that the clinic provided an inadequate response when the woman first reported extreme pain and the beauty therapist was uncertain about the correct action to take. In addition, the clinic’s first aid response was insufficient as the woman was given an ice pack for the burn, rather than running water as recommended by Hato Hone St John.

Dr Caldwell found the clinic’s procedure for TSL treatment was inadequate, as it lacked critical precautionary information about use of the TSL machine and guidance on responding to a client’s pain and providing first aid.
"The procedure did not include necessary precautions and instructions, which could have mitigated the risk of injury," Dr Caldwell said.

She was also critical of the clinic’s risk management, noting that despite a previous incident where a staff member was burned by the TSL machine the clinic continued to use it without putting in place adequate safety measures.
The report outlines several recommendations to the clinic to prevent any similar incidents in future.