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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4321

2. Registrant Information.

Registrant Reference Number: 4680171

Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.

Address: 150 Savannah Oaks Dr.

City: Brantford

Prov / State: Ontario

Country: Canada

Postal Code: N3V 1E7

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

11-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

08-JUL-11

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. 26193      PMRA Submission No.       EPA Registration No.

Product Name: Wilson OneShot Spiderban Spider Killer

  • Active Ingredient(s)
    • D-TRANS ALLETHRIN
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

unknown

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

8.0

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Oral hemorrhage
  • Unknown
    • Symptom - Other
    • Specify - Necrosis of the tongue

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Euthanised / Euthanasie

16. How was the animal exposed?

Other / Autre

specify unknown

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The Vet student said that they are trying to rule out that this product that might be involved. The student said that the owner sprayed this product in the home, but he did not know when the product was sprayed. The pet was presented to the DVM on 6/6/11 for bleeding from the mouth and now has what appears to be a necrotic area on the tip of the tongue. The pet is currently still at the clinic. The vet student was advised that possible Mild GI upset could occur if this agent was ingested. The health care operator explained to the vet student that they cannot tie all the signs to one type of toxin. Given that the calcium and phos levels are within normal levels then it is not likely the dog was exposed to a Vitamin D3 rodenticide. The hematomas could be consistent with and anticoagulant rodenticide but the other signs are not. I would rule out a coagulopathy and continue with diagnostics and symptomatic care. Several days later the vet staff called back to say the pet was euthanized.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

There is no direct correlation between the animals symptoms and the active ingredients in the product identified. In fact the animal owner could not account when he or she had applied the product and whether or not his animal was actually exposed to the product or not. One would expect acute like symptoms that are quickly resolved versus the outcome that had occurred. The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.