A woman received burns to her face after an Auckland beauty therapist used incorrect laser treatment settings.
She visited LCNZ in Takapuna for hair removal, but the therapist reportedly forgot to change machine settings to suit the client's skin tone.
After the treatment, the woman was given skincare products that were inappropriate and potentially harmful to damaged and burned skin.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found that the therapist breached the Code of Health and Disability Services Consumers' rights as she did not provide services with reasonable care or skill.
The woman didn't know about the mistake until she made a complaint, therefore Caldwell says the clinic also breached the Code by not informing her and avoiding accountability.
"I am critical of the clinic for failing to inform the woman about the cause of her burns once it became known. An error was made that caused her harm, and it is unacceptable this was not disclosed to the woman."
Caldwell also criticised the clinic's working environment as the therapist had a short turnaround time between clients that day, a stressful scenario that likely caused the error.
"The clinic has a responsibility to ensure staff have a supportive and well-resourced working environment to complete procedures. Unfortunately, in this situation the strain on staff contributed to the harm caused to the woman."
She recommended the therapist write an apology to the woman and take on further training for laser treatment and burn care should she return to work.
Caldwell further advised the clinic to write a separate apology and consider longer breaks between clients to alleviate stress on therapists.
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