Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-4967
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 2021SCPC00023888
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
02-SEP-21
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
02-SEP-21
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 100-1390
Product Name: TRIBUNE HERBICIDE
- Active Ingredient(s)
- DIQUAT
- Guarantee/concentration 37.3 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Medical Professional
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Liver
- Symptom - Hepatic failure
- Nervous and Muscular Systems
- Symptom - Other
- Specify - Cerebral edema and herniation
- Symptom -
- Specify - Almost brain dead
- Symptom - Other
- Specify - No brain stem activity
4. How long did the symptoms last?
Persisted until death
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
4
Day(s) / Jour(s)
7. Exposure scenario
Unknown
8. How did exposure occur? (Select all that apply)
Poisoning from ingestion of the pesticide
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Oral
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
2021SCPC00023888- The reporter, a medical doctor, indicates an exposure to a pesticide containing the active ingredient diquat. One day before the day of initial contact with the registrant, the reporter indicated the patient was admitted to the hospital after drinking an unknown amount of the pesticide. On the day of initial contact, the reporter stated the patient was having seizures and was in renal and hepatic failure. The reporter was advised to treat the patient symptomatically. On follow-up call one day after the day of initial contact, the reporter indicated the patient had developed cerebral edema and herniation and was almost brain dead. On follow-up call two days after the day of initial contact the reporter indicated the patient had not had any brainstem activity for an unspecified amount of time. On follow-up call three days after the day of initial contact, the reporter indicated the patient had died the previous day. No additional information is available.
To be determined by Registrant
14. Severity classification.
Death
15. Provide supplemental information here.