Auckland woman remains with scars on her face after botched laser treatment

An Auckland woman left extensive scars after laser treatment burned her face.

Monday, the former deputy Health and Disability Commissioner (HDC) released a report finding a skin treatment clinic violated the code for failing to support and educate its staff to provide an appropriate standard of care.

The unnamed clinic was also found to have failed to ensure that its staff meet the requirements of the Auckland Council. Code of good practice in health and hygiene.

The woman, in her 30s and known as Ms A, visited the clinic for broken capillaries (blood vessels) in June and July 2018.

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She received three laser sessions by an esthetician, Ms B, on her cheeks – but increased tuning in the third session burned them out.

The woman was left with burnt cheeks after her third laser treatment at the clinic (file photo).

The woman was left with burnt cheeks after her third laser treatment at the clinic (file photo).

The clinic told the HDC that its staff are trained in laser skin rejuvenation when they have at least a year of experience in laser hair removal.

Ms B graduated as a beautician in 2016 and had a laser certificate at the time the incident occurred. However, she had no documentation of training in skin rejuvenation.

The clinic required all clients to sign a consent form before any treatment. As Ms. A had previously been to the clinic for laser hair removal, she was not asked to sign another consent.

It also meant that a risk information sheet was not provided to her – which the clinic accepted as an oversight.

The HDC said treatment notes from Ms A’s first two sessions showed the laser settings to be 150 joules / 20 milliseconds and a dot size of 3 millimeters.

Because Ms. A didn’t notice much of a difference, Ms. B said it was discussed that she would increase the settings by “one” for the third session – meaning it would be 160 joules.

However, the HDC said the recordings from the third session were unclear – and appeared to represent 150 or 180 joules used.

During the third treatment, Ms. A said it was too hot, so Ms. B lowered the settings and increased the cooling.

Former Assistant Commissioner for Health and Disability, Kevin Allan.


Former Assistant Commissioner for Health and Disability, Kevin Allan.

But Ms A claimed that the setting had remained the same and that she had to end the session earlier because of the pain.

There were also conflicting reports about what Ms A had said about post-treatment care.

Ms A told the HDC: “It was very painful, there was a large amount of swelling and there were several large, oozing blisters on my cheeks.”

She contacted the clinic that day, sending photos of her skin and asking if it was normal. Clinic director Ms C texted her back, saying the blisters would go away and she was applying a cool compress.

Two days later, Ms A visited her GP with concerns about the scarring.

Her GP said she had burns from the laser treatment and her left cheek was infected.

Due to persistent scarring, Ms. A went to another clinic in April 2019 for counseling and underwent “intense pulsed light” to improve it.

Former Deputy Commissioner Kevin Allan said Ms B’s actions demonstrated a lack of knowledge and experience in the field of skin rejuvenation.

Ms. C did not provide “adequate and appropriate advice” when Ms. A indicated that her skin was blistered.

“In my opinion, the failures identified on the part of the clinic are indicative of a service provider that has not adequately supported and educated its staff to provide services at an appropriate level.

“I find that the clinic did not provide services to Ms. A with reasonable care and skill.”

Allan recommended that everyone involved apologize in writing to Ms. A.

In addition to this, he recommended that the clinic develop a staff training protocol, an informed consent policy, provide evidence of staff training on Auckland Board requirements, and develop a process. recording and responding to incidents and near misses.

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