Just hours after undergoing her first botox treatment, a woman was left with a racing heart, feelings similar to an “electrical surge” through her limbs, and “a body that felt like it was on fire”.

But while it was likely she was reacting to the wrinkle-prevention treatment, the new patient had no idea what to expect.

The procedure was performed by a clinic manager who had never registered as a nurse in New Zealand and had given no warning to her patient about the possible side effects of the drug.

In a decision released by the deputy Health and Disability Commissioner (HDC) today, the clinic manager’s boss, a doctor who owned the clinic, was found in breach of the code of patient rights after he directed this clinic manager to undertake the treatment.

The name of the doctor, clinic manager and clinic name are not detailed in the decision.

The woman was booked in for a botox treatment alongside two friends in September 2020. The clinic’s doctor, who usually undertook cosmetic treatment, was away on the day.

The clinic’s manager initially thought the patient was observing her two friends, who were returning patients. When she discovered the woman was to undergo botox treatment herself, she called her boss who told her to go ahead with the treatment.

The patient signed a consent form, as did the clinic manager who signed the form as a “doctor”. She was then injected with 30 units of botox.

She later told the HDC that there was no discussion about possible risks or side effects before the treatment. The clinic manager accepted this advice was omitted before the patient was injected.

Just minutes after her treatment, the woman noticed blood near the injection area.

The next day she felt tired and by 10pm that night had a racing heart rate, a feeling of dread, was shaking and sweating and felt like her body was “on fire”. She also spoke of feeling pain like “electrical surges” through her limbs.

She returned to the clinic, this time seeing the doctor, who found she was clinically stable. The doctor recorded she had a “mild reaction” to the botox, with “an overlay of severe anxiety”.

More than a month after the treatment, the woman said she continued to experience side effects such as vertigo and a brief inability to swallow.

The clinic manager who undertook the treatment later told the HDC that she was placed in “such a compromised and vulnerable position” by her boss. She apologised to the patient.

As a result, deputy Health and Disability Commissioner Deborah James did not find that the clinic manager breached the code, but was critical of her signing the consent form as the “doctor”, and not providing adequate information to the patient.

But James did find the doctor, who owned the clinic, in breach of the code after he directed his unqualified staff member to complete the treatment, and failed to ensure the patient was informed of possible side effects.

James also said it appeared the unqualified clinic manager had been asked by the doctor to assist with botox for other patients previously.

The doctor has since stopped practicing and the manager has left the clinic.

Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.