A botched fire cupping session resulted in a patient suffering a painful blister which then became infected with a brown residue after her practitioner treated it with a “secret formula” plaster from overseas.

The Chinese medicine practitioner then sent the woman multiple emails apologising and offering compensation, something which could have amounted to harassment, a watchdog has found.

A Health and Disability Commissioner (HDC) decision released on Monday has now outlined the importance of informed consent and knowing the ingredients of treatments used on consumers.

In July 2020 the woman visited the practitioner, identified as Mr B, at his clinic to receive fire cupping treatment for a shoulder injury.

During the woman’s seventh session on July 3 she felt pain on her back and, when she returned home, discovered a “large painful” blister.

She returned to Mr B that afternoon and he burst the blister using a needle before applying what he described as a traditional plaster to the wound. He heated the plaster over a flame, allowing it to cool before applying it to the wound.

The woman returned daily for four days to have her wound redressed by Mr B.

On July 8 the plaster became itchy and uncomfortable, and the woman asked her husband to remove it. She was shocked to find a dark sticky substance stuck to the wound.

Two days later she visited her GP who referred her to an emergency medical centre for treatment of the wound.

The next four weeks saw the woman making multiple visits to the emergency medical centre to have the residue from the plaster removed. She said this was difficult and painful and the wound also became infected.

The woman emailed the practitioner to complain about his treatment and he responded by asking how to resolve the issue. She didn’t respond.

The practitioner emailed the woman two more times, repeatedly apologising and offering a payment of $500 to her. He also called the woman repeating these offers.

The woman said she continued to tell Mr B she wanted to deal with the issue formally and not in an “under the table” kind of way.

She had made a complaint to the HDC and the New Zealand Acupuncture Standards Authority (NZASA).

Mr B was restricted from performing any form of fire cupping or moxibustion until an investigation into the incident had been completed.

The NZASA found that the use of a plaster with unknown ingredients led to a lack of safe practice and Mr B’s repeated apologies and offer of $500 was inappropriate and could be experienced as “coercion or harassment” by the woman.

It also found Mr B’s medical notes to be inadequate and lacking information and noted that the woman signed the consent form without Mr B’s presence, preventing any further discussion.

It recommended Mr B review his cupping technique, refrain from using the herbal plaster on any consumer and provide a written reflection on first aid treatment for a burn. NZASA also completed an educational visit to Mr B’s clinic.

Deputy Health and Disability Commissioner Deborah James found Mr B in multiple breaches of the Health and Disability Services Consumers’ Rights code.

James found he failed to discuss the risks and side effects of cupping treatment with the woman and she was, therefore, unable to give informed consent.

“The use of the plaster to treat the woman’s blister was inappropriate, given the unknown ingredients, lack of expiry date, quality, or licensing mark, and the fact that it was likely, not sterile,” the report stated.

James also found that Mr B’s clinical record-keeping did not meet professional standards.

She recommended that Mr B apologises to the woman, develop a full suite of policies and procedures, including informed consent and a complaints procedure, that is compliant with the Code, and arrange an NZASA audit of his patient notes.

Emily Moorhouse is a Christchurch-based Open Justice journalist at NZME. She joined NZME in 2022. Before that, she was at the Christchurch Star.