A woman spent a week in hospital and needed a skin graft after she was left with a severe third-degree burn while undergoing a body contour treatment at a beauty clinic.
The woman’s ordeal was detailed in a recently released report by the Health and Disability Commissioner (HDC), which found the beauty clinic had breached her rights. The woman, the clinic, and the beauty therapists involved in the incident are not named in the report.
She visited the clinic on June 15, 2021, to undergo thermal shock lipolysis (TSL) treatment, a non-surgical treatment in which a combination of hot and cold temperatures is used to target fat cells.
According to the report, the machine’s treatment guide said the procedure may cause “moderate discomfort, a feeling that the skin is being pulled into a vacuum, and/or a stinging or cold sensation for the first 20 minutes”. However, it is generally expected that after this, the client should feel “quite comfortable.”
The clinic told the HDC that clients should only experience a slight “warming sensation” while the machine is in its heating phase and should report any pain or discomfort to the beauty therapist immediately.
The apprentice beauty therapist who administered the treatment told the woman she may experience tenderness, stiffness, redness, swelling, and bruising in the areas being treated. The woman was fully advised of this, signed a consent form, and acknowledged that the treatment may not have the desired outcome because of human error.
The procedure
The treatment was for the woman’s lower abdomen and consisted of 10 minutes of heating at 42C, 35 minutes of cooling down to -2C, and a final 10 minutes of heating to 42C.
During the last few minutes of the heating stage, the woman said the machine had “overheated” and was causing her “extreme pain and discomfort”. This was because an applicator head had heated beyond the pre-set maximum of 42C, and the machine had no indicator to show something was wrong.
The woman alerted the therapist, who told her that the pain was normal and that there were four minutes left if the woman could “stick it out”.
The woman described the pain she experienced as “unbearable” but said she was worried that stopping the treatment early could leave her with a “frozen block of fat”.
When the therapist checked the machine’s screen before leaving the room, she told the woman that “everything looks fine, but we can remove [the applicator] if you want”. The woman said she was left to make a decision she should not have had to make.
In her comment to the HDC, the therapist said the woman told her she felt “stinging” under the applicator and looked to be in “quite a bit of discomfort”. She suggested the applicator be removed so the area could be reviewed, but the woman was concerned about the frozen block of fat.
She said the area could be massaged, but the woman told her not to remove the applicator as the stinging had “eased and gone away”. The clinic said this delayed them from removing the machine. She also told a colleague that she felt uncomfortable about the treatment and wanted to remove the applicator.
After returning to the room, the woman said the pain had become “beyond unmanageable” and asked to remove the applicator.
When they did, a “huge, popped blister, showing thick skin ripped off and a big flaming red, burnt patch of raw skin” was left on the woman’s lower abdomen.
The therapist’s colleague was also in the room and said, “Everything appeared normal” until the antifreeze membrane was removed, which “peeled back” the top layer of the woman’s skin.
In her complaint, the woman accused the two of “chuckling and commentating” about her high pain threshold. Both the therapist and clinic owner denied laughing at the woman or minimising her pain.
After the machine was switched off, the woman said she was “shaking and in shock” and “knew it was bad”. She said she “just wanted to get to a medical centre.” At that point, the owner told her the machine was being trialled. The woman was also left with a small burn when she used it. The owner acknowledged that the woman’s burn was much worse than the one she had.
Staff quickly informed the woman that a faulty part of the machine caused her burn and that the supplier would be sending a replacement.
The woman also said the level of after-care and first-aid she received was inadequate. She claims she was given an ice pack, was told the burn was “superficial”, and that she should go to the doctor for “reassurance” if needed. She said she was in “excruciating pain” and didn’t immediately question the information at the time. She said she immediately left to see a GP.
The clinic disputed her claims, saying a cold compress and ice pack were placed on the woman’s abdomen, and her wound was dressed. The clinic also said she was told to see a GP “immediately” and reiterated this over the phone later in the day. The therapist called the woman later in the day and said she was told her client had only bought burn repair cream from the pharmacy.
The therapist said she apologised to the woman and offered free treatments to deal with any scarring once the burn healed. She also said the clinic would cover the cost of any medical treatments she may need.
After a few trips to the GP, the woman was admitted to hospital, and it was found the treatment left her with a “severe” third-degree burn.
As a result, the woman needed a skin graft and was kept in hospital for almost a week.
Clinic breached woman’s rights – Deputy Commissioner
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the clinic had breached the woman’s rights.
Caldwell said several “systemic issues” had contributed to the incident. These include an “inadequate response when the woman first reported extreme pain” and the beauty therapist being unsure about what to do.
Caldwell also found an issue with the level of first aid provided to the woman.
“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,” she said.
Caldwell called the clinic’s procedure for the treatment “inadequate” as it lacked “critical” precautionary information about the use of the machine and guidance on responding to a client’s pain and administering first aid.
“The procedure did not include necessary precautions and instructions, which could have mitigated the risk of injury,” she said.
She was also critical of the clinic’s risk management, stating that the machine was still being used despite the staff member having been burned by it previously.
Caldwell recommended that the clinic write an apology to the woman and provide first aid certificates to confirm that at least one staff member with training was always present.
Following the botched treatment, the clinic acted to ensure similar incidents wouldn’t happen again.
This included replacing the machine’s faulty head, requesting a software update, updating its TSL protocol, and sending three staff members to undergo first aid training. The clinic’s lawyers also helped draft an updated safety and treatment policy for the machine.
The clinic said it stopped using the machine after events and would not use it again until it was satisfied that the protocols and testing it implemented would prevent the same fault from happening again.
The clinic’s suppliers were also reviewed, and it moved to purchase most machinery from New Zealand suppliers.
