A woman suffered burns to her legs during a painful laser hair removal treatment by an inexperienced beautician.

She was still suffering when she got home from the appointment and around half an hour afterwards, her partner called the clinic saying he was concerned about her legs.

He was told by the clinic to apply ice, send photographs and for them to return to the clinic as soon as possible.

Upon arrival, it was clear that she had suffered burns and steps were then taken to understand what had happened.

Now, the Heath and Disability Commissioner (HDC) has found that the clinician who treated the woman mistakenly set the laser machine to the wrong skin type.

According to a decision released today, the clinician had become qualified as a level five beauty therapist six months earlier and had become qualified in laser hair removal only three weeks before the incident.

The decision described how the woman attended the appointment in June 2021 for laser hair removal, which she had received on several occasions over the previous two years.

She told the HDC that before commencing the treatment, the clinician didn’t check the laser settings.

The clinician said she undertook her usual preparation, which included checking that the woman had provided informed consent, noting the treatment number, taking notes of previous treatment plans, analysing hair growth, reviewing the notes on initial consultation and updating photos of the treated area, according to the findings.

Based on that information, she developed a treatment plan and adjusted the settings in accordance with the thickness of hair, skin type, and genetic background and completed a double check to make sure the settings were correct, she said.

She told the HDC she performed a test patch prior to completing the full treatment, in line with the clinic’s protocol.

But the woman disputed that had been done and clinic’s records didn’t mention whether a test patch was undertaken in the prescribed form.

It was noted that there was no requirement on the progress notes form to record whether a test patch was completed and, if so, the results.

The woman claimed she told the clinician to stop the treatment because of the pain, but the treatment continued.

She told the HDC that because she was wearing goggles and was lying face down for half of the session, she couldn’t see and was afraid to move and have the laser burn her.

The clinician told the HDC the woman didn’t ask her to stop the treatment, and that had she been asked, she would have stopped immediately.

She recalled the woman being “fidgety” which prompted her to stop several times to ask if she was okay to continue.

She said the woman told her the pain “was fine”, she “was okay”, and that “she could handle it” as the treatment continued.

There appeared to have been no real focus on the outcome sustained, which was not only physical damage to her skin, but also emotional distress, financial loss, and a significant impact on her career timeline, the findings said.

Following the treatment, the woman’s legs were swollen, and when she asked the clinician whether that was “normal”, she was told “yes”.

The clinician applied recovery cream and sun protection factor, and went over post-care information with the woman.

The clinician and the clinic told the HDC it was not uncommon for skin to swell and for some irritation to occur post-treatment, and that the clinician initially thought the swelling was a normal reaction to inflammation of the hair follicles.

Before leaving the clinic, the woman booked her next appointment.

When the woman returned to the clinic after her partner’s distress call, various products were provided to help address the burn injuries.

The clinic told the HDC it advised her to visit accident and emergency, but the woman said she was not given that advice.

The decision states that on reviewing the clinician’s notes the clinic discovered that she had mistakenly set the laser machine to the wrong skin type.

The clinic said it apologised and said that any costs incurred for medical care would be reimbursed.

The woman told the HDC that medical costs were covered for the first one or two weeks after the incident, but stopped after that point.

The HDC sought independent advice and it was identified that there were multiple departures from the accepted standard of care.

The laser burns were identified as a “severe” departure from the expected standard of care.

Based on conflicting evidence the HDC found it was more likely than not that a test patch didn’t occur and the level of pain reported during the procedure should have prompted the clinician to stop and reassess the situation.

The HDC found the appearance of the skin post-treatment was not “normal” and accepted an adviser’s opinion that the appearance of the burns was not consistent with inflamed hair follicles.

It was found that the clinician lacked experience and knowledge to fully appreciate that, at the time, the woman was suffering injury from the laser.

The HDC found there was concern about the time it took the franchise head office to make contact with the woman directly, the lack of support provided to the clinic, and the six-month delay in providing a formal apology for the incident.

“There appears to have been no real focus on the outcome sustained, which was not only physical damage to her skin, but also emotional distress, financial loss, and a significant impact on her career timeline,” the findings said.

The clinic’s head office told the HDC it had taken the comments and lessons from the incident very seriously.

It said it had been working with franchisees to make several changes to policies and procedures.

The clinic told the HDC it had adopted protocols for laser hair removal and management of skin post-laser treatment, regular reviews of notes and laser settings, and training on codes of rights.

The clinician told the HDC she had undertaken further training and now double-checks the laser settings while doing laser refresher training every six months.

The HDC recommended that the clinician be audited by the clinic to check laser accuracy from 20 assessments, which would then be provided to the HDC within three months of the findings.

She was also told to provide evidence that refresher training on laser assessments had been completed and apologise to the woman.

In a provisional report from the HDC, the clinic had been told to adopt changes which had since been accepted.

Figures supplied to NZME by ACC show there were 19 claims for injuries related to laser beauty treatments in 2025. That was the same amount as 2024 and up from 15 in 2023.

Al Williams is an Open Justice reporter for the New Zealand Herald, based in Christchurch. He has worked in daily and community titles in New Zealand and overseas for the last 16 years. Most recently he was editor of the Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.