The Health Care Complaints Commission placed a prohibition order on Ms Huirong Zhou, a non-registered practitioner, following a Botox treatment she administered to a patient causing iatrogenic botulism and persistent difficulty swallowing and speaking. Ms Zhou is now prohibited from providing any paid or unpaid health services for five years from 19 May 2026, the date of the effect of the prohibition order.
In issue
- The Health Care Complaints Commission (the HCCC) sought to determine whether Ms Zhou breached the Code of Conduct for non-registered health practitioners (the Code of Conduct) following her administration of a Botox treatment which caused iatrogenic botulism and persistent difficulty swallowing and speaking.
The background
Ms Zhou was the sole director and owner of Rui Mei Beauty Salon, located in Burwood, where she performed 'advanced facial treatments' along with other cosmetic services since 2014. Ms Zhou’s qualifications included a Diploma of Remedial Massage and Beauty Therapy and Advanced Diploma of Intense Pulsed Light (IPL) and Laser for Hair Reduction. She was not registered in any health profession.
On 15 October 2025, a 62-year-old female patient (patient A) was admitted to Canterbury Hospital presenting with four days of symptoms consistent with iatrogenic botulism, primarily dysarthria and dysphagia. Patient A was later admitted to ICU for a period of five days.
Patient A reported that she had received Botox and hyaluronic acid injections from Ms Zhou two weeks prior. She gave a statement that at the time of the procedure, she had not been informed of the product nor the quantity that was being injected into her face. Patient A further stated that she had exchanged WeChat messages with Ms Zhou during the course of which Ms Zhou had advised her that her adverse reaction was normal. While patient A recovered to some extent, she continued to suffer from difficulty swallowing and speaking.
Following the incident involving patient A, an inspection of Rui Mei Beauty Salon was carried out by officers of Sydney Local Health District Public Health Unit, Burwood Council and Pharmaceutical Services Unit on 20 October 2025. The inspection report noted a number of concerning issues, including:
- no employees of the business were registered health practitioners
- multiple overseas-sourced injectables including botulinum toxin, dermal fillers, vitamin injections and peptides were located and seized
- medications were not stored in an inappropriate fashion, being stored in fridges with food products
- ancillary products such as needles, syringes, saline and antiseptics were not approved for use in Australia
- concerns were identified around infection control, with no sharps containers or approved and calibrated autoclave identified, and no dedicated sink for cleaning equipment
- reusable skin penetration articles were found in an unsterile condition, and
- appropriate records were not kept, and those which were found were mostly in Mandarin.
It was further noted that during the inspection, Ms Zhou was uncooperative and was found to be removing items from the fridge and deleting appointment information from her device.
Following the inspection, the Sydney Local Health District Public Health Unit issued a prohibition order requiring Ms Zhou to immediately cease skin penetration procedures at the premises.
Ms Zhou made submissions to the HCCC, claiming that she did not commercially provide cosmetic injections to the public but rather used them on herself. She further claimed that in the past, she had administered cosmetic injections to 'certain long-term clients', however this was contradicted by her WeChat messages with patient A, in which she stated she had been administering injections to a 'steady stream' of clients for the past fifteen years.
On 16 April 2026, the HCCC proposed to take action against Ms Zhou under section 41A of the Health Care Complaints Act 1993 (NSW).
The decision
The HCCC had regard to Division 1A of Part 3 of the Poisons and Therapeutic Goods Act 1966 (NSW) and Part 3A of the Poisons and Therapeutic Goods Regulation 2008 (NSW) (the Regulation), which held that it was an offence for a person other than a nurse, under the direction of a nurse or medical practitioner, to administer botulinum toxins for human use. The HCCC therefore found that Ms Zhou had unlawfully administered botulinum toxin (a Schedule 4 medication on the Poisons Standard) to patient A.
The HCCC further found that Ms Zhou’s conduct had breached the Code of Conduct, including as follows:
- Clause 1(1) – the HCCC noted that the Ms Zhou obtained, stored and administered Schedule 4 medications in breach of the Regulation and that the inspection of her premises identified concerns relating to hygiene and sterilization.
- Clauses 1(2)(a), (c) and (d) – the HCCC found that Ms Zhou did not possess the relevant qualifications or registrations which would entitle her to administer Schedule 4 medications.
- Clause 4(1) – the inspection was noted to reveal that there was a lack of dedicated sharps containers or a dedicated sink for cleaning skin penetration articles, as well as possible reuse of single-use skin penetration equipment.
- Clause 4(2) – Ms Zhou’s salon was not authorised by Burwood Council for the purposes of skin penetration procedures such as cosmetic injectables.
- Clause 12 – Ms Zhou failed to maintain clinical records.
Based on these findings, the HCCC concluded that Ms Zhou posed a serious and ongoing risk to the health and safety of the public, warranting a prohibition order.
Implications for you
This case highlights the clear distinction between treatment that can be provided by registered practitioners who are regulated under the ‘National Law’ and non-registered practitioners, the latter of whom can still be restricted or banned through separate regulatory frameworks. The serious patient outcome, including the ICU admission, was a key concern in the assessment of clinical risk and patient harm, as well as whether the practitioner’s conduct amounted to an ongoing risk to the public so as to justify a prohibition order.
Regulators clearly possess extensive preventive powers that encompass both unsafe and unregistered individuals who may falsely present themselves as qualified health practitioners. This is particularly significant given the growing patient demand for cosmetic procedures involving skin penetration treatments, such as Botox injections, fillers, and microneedling. Overall, the case underscores a distinct regulatory trend: increasing oversight of cosmetic procedures, especially where providers operate outside traditional medical registration frameworks.
